Atrial Fibrillation, safety of Catheter Ablation with a Pacemaker?

Needs an endocardial tracking system

by crustyg - 2020-12-17 06:01:09

Hi Gemita:

I think that there are two aspects to this. 1) Avoiding damaging the existing leads, 2) avoiding damaging important (mostly conducting) parts on the inside of the heart.

1 is relatively easy, I think: lots of fluoroscopic imaging to show where leads are as the EP-doc steers the ablation catheter around.  Since ablation leads (2) will go into femoral vein and into RA (mostly) there's not a lot of potential conflict - the PM leads go into sub-clavian vein and in from SVC into RA.

2: There are a couple of clever ways to show 'precisely' where the tip of an ablation catheter is, in relation to the conducting structures of the heart.  A location cath is popped into the mouth of the coronary sinus  - very stable anatomy, it's in the same place on almost everyone, gives a good reference point.  Using either of the two technologies for locating, in 3D, where the ablation cath is actually located (referenced to the coronary sinus, checked with fluoroscope), the ablation cath is steered to the desired point and allowed to touch the heart muscle - at this stage it's only listening/detecting the electrical activity.  Not quite correct, move it, and re-touch.  Once the EP-doc is certain that it's in the correct place, quick blast of X-ray on the fluoroscope to check that pacing leads aren't physically touching, and hit the floor switch to activate ablation tip =>burn piece of heart tissue. Leave lead in place, look for electrical activity.  Repeat as necessary.

Skilled stuff, but plenty of safeguards.

HTH.

Ablation procedure

by Gemita - 2020-12-17 11:32:57

Thank you crustyg for your helpful, positive post as always.  May I confirm that a patient with a pacemaker shouldn’t necessarily be disadvantaged in any way (in skilled hands of course) if they needed to go ahead with a Radio Frequency Catheter Ablation for Atrial Fibrillation?

I suppose my overriding concern during the ablation would be the fear of somehow displacing the pacemaker lead tips attached to the heart, overheating them during the procedure, breaking them, causing them to malfunction;  or damaging/overheating my device in some way, losing precious data and things like this.  Also, I was concerned the leads might get in the way, making the procedure more complex than it would otherwise have been, and possibly coming out of the procedure in a worse state than when I went in, if that all makes sense.

I take your point about the ablation leads being fed up the femoral vein and the pacemaker leads being in the subclavian vein, so well clear of each other, but won’t they meet in the right atrium as the ablation leads are fed into the left atrium and couldn’t the ablation leads potentially cause damage to the residing pacemaker leads on their way through?

So you believe the pacemaker and leads are safe during an ablation procedure?

Do they have to do anything like de-activating the device (placing in safe mode), downloading any data etc. prior to an ablation in case of any mishaps??  

Did you have your ablation before your pacemaker crustyg or afterwards??  

Do all good EPs use an Endocardial Tracking System when carrying out an ablation ? 

You make everything sound fairly routine.  Care to come and do the job with my EP?  I think I would feel safer to know you were there.

Your post largely focuses on the care required to avoid conduction system damage and if I am honest my biggest concern would be coming out of this procedure in a worse position than I am in at present.  From your post I can see how important it will be to have a specialist team doing the procedure.  Of course the actual procedure details is a subject for another post, but I am reassured that in skilled hands I would be safe having an ablation with a pacemaker.

It's a skilled procedure

by crustyg - 2020-12-17 11:56:18

My two ablations for classical CTI-AFlut were before PM.  First was done without endocardial tracking and second with.

I'm pretty sure that the PM would need to be in diathermy-safe mode for this procedure so probably pacing at a fixed rate.

There is *always* a risk of damaging one or other PM pacing leads during an ablation, but with skill and care (use of real-time X-ray - fluoroscopy) that risk should be mitigated. It depends a little on lead placements: my RA lead (in RA-appendage) has a fairly large loop towards the tricuspid valve, and is pretty posterior as it descends in my RA - the appendage is an anterior structure. RV lead is much the same, so I *think* they are fairly well out of the way.  All very clear on a fluoroscope.  Simple dislodgement of existing, well bedded in leads would be unusual, I think.

There's no doubt that if you can, you should select the ablation operator for their track record of skill and success.

There's a whole other discussion about ablation for AFib.  Several contributors here have had it, with varying degrees of success.  I believe that time already spent in AFib is a significant factor in long-term success of staying out of AFib, and different patients have different causes of AFib so ablation may work better for some than others.

It's lovely that you say such nice things: my key skill is explaining complex things to make them seem simple (essential in Technical Sales), but I don't begin to have the skill to make any comment on folk who steer catheters around the human body as part of their jobs.

RA/LA

by AgentX86 - 2020-12-17 13:33:50

Gemita,  I'm confused by your statement:

"...being in the subclavian vein so well clear of each other, but won’t they meet in the right atrium as the ablation leads are fed into the left atrium and couldn’t the ablation leads potentially cause damage..."

I'm not sure what you're getting at here.

Leads and ablation catheters are fed into the RA, which is why the femoral and subclavian veins end up (indeed all veins except the pulmonary vein end up in the RA).  If access to the LA is needed the catheter enters the RA and has to punture the septum to access the LA. 

My three ablations for atypical flutter had to go through the septum as atypical flutter occurs in the LA and veins lead to the RA. To get to the LA directly, access to the pulmonary vein would be necessary, which would be rather difficult and dangerous.

Agent X86

by Gemita - 2020-12-17 16:28:48

Yes that didn’t read very well.   I was trying to say that since the femoral vein would be used, I suspect, to feed any ablation catheter leads up into the right atrium, the pacemaker leads and ablation leads would not come into contact until the ablation leads reached my heart where my pacemaker leads reside (RV septal/RA endocardial) sites?  Am I correct so far in my understanding?  When the ablation leads reach the heart, particularly the right atrium, that is the stage where the ablation leads could potentially do a lot of damage to pacemaker leads, if ablation leads are not carefully controlled, that is what I meant to say.  I realise a PVI ablation would require entry from the right into the left atrium.  By the way my pacemaker leads are in my axillary/subclavian vein (RA endocardial site)/RV Septal site.  

AgentX86 it would be nice to have your opinion on the safety of a catheter ablation with a pacemaker?  Does a pacemaker complicate the procedure, increase the risks, make a successful outcome less likely or in the right hands, would it make no difference?  Thank you

Ablation w/Pacemaker

by AgentX86 - 2020-12-17 18:31:38

Your physiology sounds right.  The PM leads enter through the superior venacava on the upper(ish) part of the heart, into the RA.  The LV lead then goes through the tricuspid valve from the RA into the LV.  An ablation cath would enter the RA through the inferior venacava lower in the RA.  I think your concern is the catheter passing by the RV lead.  Yes, it sounds scary to me but Crusty has covered the mechanics of this pretty well  (thanks, fluroscopy always amazed me - I can't see a thing in the pictures).

I'd think a PM would make the risk somewhat greater (it's impossible to believe that it would reduce risk) but I don't see it as an impossible task.  I don't see an ablation (without PM) as being very risky.  Major problems are exceedingly rare.  That said, with a pacemaker I'd certainly want to go to one of the best (in the world) to have it done.  I don't think the outcome would differ much because of the PM but there is a very large difference in the outcomes between the top tier EPs and also rans.  In this case, one and done would be even more important IMO. 

Bottom line:  If I thought it would make my life better, I'd do it.  But at the same time I'd really want to make sure it worked and didn't have to do it again.

Thank you AgentX86 and crustyg

by Gemita - 2020-12-17 19:31:44

Between you both I have got some really useful feedback.  

No in my case it probably wouldn't be a one and done case I am sure and that would double my risk of exposure to potential risks with a pacemaker.  

I haven't yet had this conversation with my EP.  I think he thought I was heading for an AV node ablation which would have been simpler and a shorter procedure although I know this should be a last resort option as you keep reminding me AgentX86 and it will be.

You are right crustyg that "time already spent in AFib is a significant factor in long-term success of staying out of AFib, and different patients have different causes of AFib so ablation may work better for some than others".  Your latter statement is what bothers me most - not sure how well my cause for AF will react to being burned and controlled and I won't know until I have had the procedure by which time there is no going back

Ablation

by AgentX86 - 2020-12-17 23:04:17

Sure, there are many sites that can cause AF, some are easier than others.  For most, a simple cryogenic PVI will do it.  In others, the EP has to try to force AF to track it down where it lives.  A very few will go as far as isolating the LAA.  Most won't touch the LAA because of the possible clotting consequences.  This is why the top EP is needed.  These decisions have to be made the first time and then it's only about 80% effective, IIRC.  A "touch up" is often needed to finally kill the beast.  The better the ablationist, the better your chances.  You shouldn't even consider an EP who does less than a hundred per year and a thousand overall.

I guess I haven't said it directly but only consider an ablation if the Afib/flutter is so bad that it affects your quality of life.  I know several who are completely asymptomatic.  They'd be foolish to have an ablation at anytime.  Treat the issues (anticoagulation and rate control) and be done with it.

At the other end of the extreme, if you're like I was and can't sleep/function, anything is worth a shot.  ...and I tried everything until those "tries" caused SSS. My EP had been talking about an AV ablation as an option for a year but it seemed extreme until the pauses got to a dangerous level.  Once the PM was no longer an option, an AV ablation wasn't a Giant leap, to finally slay the dragon. Well, more like "wall in the dragon s it can't be seen".

I'm sure you will think long and hard about an AV ablation.  There is no going back and at least in my case AV dyssynchrony (VVIR) is forever.

AgentX86

by Gemita - 2020-12-18 04:46:04

No I guess you haven't said it directly "but only consider an ablation if the Afib/flutter is so bad that it affects your quality of life" but I am glad you have said it now!   I know exactly what you mean.  Before my pacemaker, I didn't want to go on living feeling as I did.  I would have done anything, tried anything to stop my rhythm disturbances.  My life was a mess, really miserable.  

The pacemaker has made such a difference.  I am now less symptomatic during an arrhythmia like AF and symptoms are usually the driving force to getting something done like an ablation, otherwise at least here in the UK they may not encourage having an ablation, even though we all know the potential harm AF can do.  It seems in the States an ablation is more readily available as a treatment option, together with anti arrhythmics/rate control meds and this I feel is good because an ablation is clearly more effective than medication.  I think attitudes are slowly changing here too and this is a very good thing for patients who are clearly looking for a better way to treat their AF.

As you say, providing rate control meds and anticoagulation are given when needed, many doctors may choose to leave well alone in patients who are unaware of their rhythm disturbances.  I chose my pacemaker because I knew ultimately I would need one for my Sick Sinus problems and I was fearful of making things worse with an ablation.  I think I made the best decision at the time although my rhythm disturbances are beginning to build again unfortunately, hence the reason for this post

Ablation After Pacemaker

by Marybird - 2020-12-18 15:19:37

Gemita, I'm so sorry to hear your arrhythmias seem to be rearing their ugly heads again. They must be getting miserable for you to even think of going through an ablation to get rid of or improve them.

I just wanted to mention that my daughter (age 36) went through at least two, maybe 3 ablations after her pacemaker was implanted in January 2012. 

She had several ablations before the pacemaker for unrelenting atrial tachycardias (including one for afib)  beginning in her mid-20's. These apparently came from multiple locations in the atria, and included afib at times, sinus tachycardia. She had a resting heart rate of 130-140 and this increased to around 200 or so with minimal activity. This went on for several years till it was constant and the EP informed her, and us, that if it went on she would die. Apparently the main culprit sites were either in, or very close to, the sinus node and the EP ablated the sinus node, which left her needing a pacemaker. I'm not sure they do that anymore, now there are medications that act directly on sinus node electrical signals ( Corlanor), but this was not available in the US at the time. 

She got tachycardia again, apparently from new sites, and she had at least two ablations after the pacemaker was inserted. They didn't seem to have any concerns about the pacemaker with those ablations, and I don't recall any issues with the pacemaker after the ablation. What did become a concern was that apparently one of the sites causing the tachycardia was very close to one of phrenic nerves, and one ablation that had been attempted ( by another EP, not her main guy) had actually partially fried that nerve. This was picked up by her main EP ( who's stellar, and I'd trust him with my life) when he noticed looking at a fluoroscopy during a subsequent ablation that both sides of her diaphragm were rising unequally during inspiration. Fortunately she hadn't had any noticeable breathing problems and the nerve healed after some months. 

But they were afraid to do further ablations because of the proximity to that phrenic nerve, despite her continuous tachycardia, and finally they decided on an epicardial ablation. This was done through a thorocotomy ( think that's when they get to the heart through an incision on the side, between the ribs?), and this successfully eliminated that constant tachycardia for good. She still gets some tachycardia, but takes a low dose beta blocker ( atenolol) to control it, and it seems it's been even better with a pacemaker generator change she had this summer. Knock on wood, of course. 

The EP who implanted my pacemaker mentioned the possibility of ablation in my case if it was frequent enough and symptomatic despite increases in medication and the use of antiarrhythmics. So I know having a pacemaker is not a problem for doing ablations. I don't see myself submitting to an ablation, but perhaps that's just abject ( and perhaps unjustified) fear on my part.. I might feel differently if tachycardias/arrhythmias made me miserable too much of the time. I must admit I would be very much relieved to think medications ( especially just rate control meds) will always be enough to keep my "furies" under control, LOL.

In your shoes, though, I'd take all your concerns and questions to your EP. They're valid and the EP should be willing to explain it all to you, so you can make informed decisions. Good luck with it!

"heart through an incision on the side, between the ribs"

by AgentX86 - 2020-12-19 00:49:03

I don't know if what she had but this sounds like a "Mini-Maze" which is kinda like an endoscopic maze procedure.  Next to a real maze procedure, it's probably the most effective treatment for atrial arrhythmias.  That said, the real maze procedure stopped my Afib but traded it for permanent flutter.  Nothing is foolproof.

Marybird

by Gemita - 2020-12-19 12:27:56

Dear Mary,

It was so kind of you to write about your daughter’s personal battle with tachycardia/AF and how she has suffered over the years from such a young age.  I am glad that she may finally be over the worse and that her pacemaker and pacing were not affected by her several ablations.  This was very reassuring, so thank you for that information.

My situation is that I also have arrhythmias firing in several different locations in the atria and I have been told I could well need several ablations to clean all this up, so the prospect of going down the ablation route for an indefinite period fills me with some dread, especially at 72.  If it was a one and done, I would do it today, but sadly this is not likely to be the case.  I have already had an EP Study done (this really should have been my first ablation attempt opportunity rather than just having a look around study), so one opportunity was missed, when I was clearly in AF for the whole procedure and the arrhythmia location was seen at the time - very rapid fractionated (disorganised) signals in DCS>PCS (believe means distal to proximal coronary sinus area), so presumably that would be one ablation site?

During my last pacemaker interrogation, it was extremely difficult for my technicians to tell me which particularly rhythm disturbance was present during one very symptomatic episode that was flagged as a significant event.  Initially they said Flutter.  During the arrhythmia I became extremely unstable for several hours and I really should have sought help.  I have since had further symptomatic episodes, but none of them as long lasting as the one I had a few months ago.  The pacemaker technicians consulted both my EP and the Medtronic Technician for a definitive diagnosis of what they had found.  They wrote in my final report “patient appears to have multiple focal atrial activation (sinus and other atrial onset) due to different kinds of morphologies.  The reason why MAT (multifocal atrial tachycardia) is plausible is that at times the sinus beats are present with a similar morphology and rate and at other times a completely different morphology is present (narrow high amplitude vs longer low amplitude)".  

I have ‘confirmed’  Atrial Flutter, Afib, SVT and now MAT (multifocal atrial tachycardia) as well as runs of VT (non sustained), so quite a lot going on at times.

To be honest, because of the “in and out” nature of my arrhythmias, I can quickly get respite from them most of the time unless I have a long lasting episode which can occur at any time out of the blue.  This is when it gets really tough and when I can get quite incapacitated.  My heart is strong though Mary (so they tell me) but my EP will do an ablation whenever I ask for one.  So far my pacemaker is doing a grand job and I feel my arrhythmias less and have fewer symptoms overall but my arrhythmias are clearly increasing so, as you say, I need to have another meaningful conversation with my EP when I next see him in the New Year, COVID-19 permitting, to get his opinion. 

My Mode Switch programme is in action multiple times a day, at least three times a week so that is the frequency of my events, some arrhythmia episodes lasting hours, but sometimes just minutes of the in and out stuff all day long and no doubt it is using a lot of battery power to Mode Switch during these short episodes.  I wish my heart could make up its mind whether to go regular slow, regular fast or irregular slow, irregular fast and to do so with a bit more respect.  It drives me crazy at times and when I feel (and see) my blood pressure/heart rate bouncing from one extreme to the other, it does amaze me how well I am coping but it is heavenly when I stay in normal sinus rhythm.

Don't Think It Was a Mini-maze

by Marybird - 2020-12-19 19:09:04

Agent, as I understand it, after a number of years and multiple ablations trying to eradicate my daughter's tachycardias, and advances in mapping instrumentation, they were able to identify a site in her atrium ( site of first activation, I think they called it?) they believed was responsible for her incessant tachycardia. But it was too close to the phrenic nerve for them to ablate that site using an intracardiac approach, without damaging the nerve. That's when they decided to ablate it using an extracardiac approach. A cardiac surgeon did the surgery to give the EP access to the outside of her heart, and they ablated the site from there. The whole thing went very quickly, and in fact the surgeon's people commented that hers was the first case for them where they accessed a heart for an external ablation. The ablation was successful, though she developed a pericardial effusion and was pretty miserable for a couple weeks after the surgery.