Pace and ablate, on the face of it, seems like the ideal solution for AF, yet is seems to only be offered when all other treatments have failed. Do any of you knowledgeable people know why it is a last resort?
Pace & Ablate - why a last resort? - Atrial Fibrillati...
Pace & Ablate - why a last resort?
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LadyLawson
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BobDVolunteer
Do you really want to have to rely on a machine if there is an alternative?
It’s quite complicated (which is why I’m not attempting to explain it fully) but there are downsides to it. The earlier you have it the more changes of pacemaker you would need, risking infection. Nature intended our heart rate to vary and pace and ablate limits that. If you only have one lead your ventricles can go out of synch. I hope that’s correct as far as it goes but happy to be corrected or improved on! I think CDreamer is very knowledgeable.
I think "last resort" is a bad way to frame Pace and Ablate. For many it's the best resort and truly a lifesaver after many attempts to treat afib otherwise. What Pace and Ablate does is not only regulate your heart rate, but also hopefully gets you off all those drugs we take to stay in sinus rhythm. Drugs that sometimes cause us as much, if not more discomfort than the afib itself.
So why isn't it used as a first resort? Besides the fact that you will be machine dependent, you will also still be in afib, albeit at a low heart rate and again, hopefully without drugs. All things equal, most will function better in sinus rhythm than in afib. Therefore why we try things such as rhythm control drugs and ablation first.
Jim
I have always thought of pace and ablate with some affection but still as a last resort just because of being machine dependent. However I am now at decision point and my new EP who I trust more than others and who I truly believe has my best interests at heart, wants me to try amiodorone first so that I have truly tried all other avenues. I think he thinks I will be more ready to accept the apparent reduction in exercise capacity that may come with pace and ablate, if I have tried everything there is to try. I am not so sure and still dithering. I wonder how other EPs view it .
Wish I could be more helpful but as you can see I am confused myself. X
Hi
Very little change in ability to exercise after pace and ablate. The worst thing was having tachycardia before the P & A which made it impossible for me to do much of anything. I get why it’s last resort because of pacemaker but once you get past 65 the docs are more likely to suggest it although they still like to see if meds work first. After trying many different meds to slow me down which made me sick I said no to the amioderone family of drugs knowing if the milder ones made me ill it was pretty certain anything else would too. I was just not willing to put anything that toxic in my body as well. I already had a pacemaker due to damage to sinus node after 3rd ablation so it wasn’t as big a decision but STILL weighed heavy on mind . These decisions are so difficult. It’s our heart.
❤️
it’s obvious your doctors have what’s best for you at heart. I was supposed to be on another medication and kept in the hospital several days being monitored following a cardioversion to see if I would stay nsr. Unfortunately, none of that came to be because three shocks with the cardioversion failed, so there was no need to go further with the meds. After this is when we went to the next step that we had discussed, which was going to be pace and ablate. They did not take this lightly, but this was the final step no more testing with other things. The point of all of this is to give us a break from a fib there is no cure, but they want the least invasive with the best result. 2 1/2 years is more than enough time to try to find an answer and meanwhile my heart was suffering and I had begun heart failure. This is why the pace and I’m late for me was the right thing for me. My heart could no longer take the trauma that it gets with every attempt, whether it be a medication’s oblations or cardioversions. For me, it was the best thing that could have been done but that being said, don’t expect a magic wand it’s going to take time to feel right. I have been told it could take up to a year I had mine done in March. I have had incredible times and I have days that are so great but nothing like I used to deal with. You will feel flutter or whatever your arrhythmia is. Just remember it can longer hurt your heart will just annoy you and know you’re not gonna feel great, but the the fear I had was damage and that’s not happening now, so I take a deep breath and I roll with it. It’s not that often and it’s not that bad.
if you trust your doctor and he has been doing right by you as mine had you will know what to do. It’s your choice. Don’t let them scare you that it’s a machine because if your heart is not working well what good is it? It’s like keeping a food mixer that no longer works, it’s not gonna do anything for you. All my AV node did for me was mess up my heart. I don’t miss it.
Some good replies above. The pace part is easy - a pacemaker is implanted but unlike other pacemakers which only cut in when your heart rate falls too low, this pacemaker is going to be your only means of initiating the electrical signal which makes the muscle of the heart contract and regulate your HR - after the AV node is ablated. The AV node is your body’s natural pacemaker. As already described, there are several types of pacemaker - 2 lead and 3 lead. A 2 lead pacemaker will put a lead into the right atrium and right ventricle. Because only one side of the heart is paced there is a possibility of heart failure within about 5 years because gradually the ventricles, one paced and one not, going out of sync is common, thus decreasing the heart’s ability to pump blood around your body effectively resulting in symptoms of heart failure.
RST or resynchronisation pacing is more complicated and the expertise required to competently attach a lead onto the left ventricle requires specialist training and practice and even then, there are complications as the lead may detach, I know as that is what happened to me, so that then requires a second procedure to reattach, not a pleasant experience. Surgeons with the knowledge, skill and expertise are few and far between.
Your pacemaker will require replacing about every 10-12 years as that is the current life of a battery. If done too young you would need 2-3 replacements during a lifetime so the likelihood of this procedure being offered to anyone under 65 is rare. Every procedure runs the risk of infection - one thing you really don’t want around your heart.
After all that - Pace and Ablate will not stop your AF. Your pulse will now be regular but the AF may continue. This means that you will still feel palpitations, your heart will still not pump blood as effectively around your body so although you may have an improved quality of life, it will still not be as effective as a heart in NSR.
That is why it will always be a last resort procedure - the benefits must always outweigh the accumulated risks so all other options should be ruled out prior to this type of procedure.
On the bright side - for me pacemaker alone seems to work very well so the ablation of the AV node was postponed - that was in 2018 and I’m still doing well with just the pacemaker.
Your post on PM and Ablation was of really interest to me. I had, as last resort, a PM put in on 28/07/23. My EP had said I would have the Ablation in August, but it has been delayed because the doctor has “forgotten” to tell the nurse to book me in for the procedure. I was very upset since I have now to wait until Nov/Dec for it. But after reading your post, I’m wondering if he is just waiting to see if, like in your case, the PM only would do the job. However, we are all different, in my case as I suffer from ‘pulsatile tinnitus’ that keeps me awake or semi awake all night. I’m felling I’m going insane without having a good sleep for years. AF since 2011 and permanent for more than 5 years, I’m 85, poor me!
I thank you for your comment.
I’m 80, well on Thursday, had pace and ablate late last year. I too have pulsatile tinnitus and am in AF 100% of the time. whilst I can hear my heart beating, can’t feel the palpitations
Yes this happened with my cousin who was just over 65 when he had problems and then eventually had a Pacemaker at around 71/72 and was due to have the ablation but was doing so well with the pacemaker they decided not to do it. So far all doing well.
When I first found that my AFib was here to stay, constantly, I thought that pace & ablate would be the next step. However, the first thing has been rate control, and only if that doesn’t work out for me will I be offered pace & ablate.
I guess it is for all the reasons mentioned. It might be in my future, but for now my rate is controlled with Bisoprolol, and of course I have anticoagulants as I’m in that age bracket. I can mainly forget about it, apart from some leg tiredness on hills and stairs.
Pacing technology seems to be developing rapidly, including ‘conduction system pacing’, which sounds as though it can attain a more ‘natural’ rhythm without the lack of synchrony mentioned in other replies.
I’ve been laughing at myself this weekend. First proper holiday since the A Fib, and I thought ‘Venice is flat’ - forgetting all the bridges! So a weekend of numerous steps in the heat, and really that was ok.
I had a pacemaker fitted after medication failed and I had a CA, now waiting for the AV ablation, so will be reliant on pacemaker,
As mentioned age seems to be a big factor. I'm 48 but having had AF for nearly 20 years I had been running out of options and pace and ablate was discussed, with reticence.I'm currently doing OK having had an unexpected run of nsr which began 5 months post third ablation (first time I've been in nsr for over a decade) but pace and ablate remains a future option.
Obviously at my age I might require multiple battery changes (risk of infection) plus the younger you are, the higher the risk of complications like heart failure down the line, following the procedure...so I'm told. I'm currently in asymptomatic or early stages heart failure so that is one of the factors to consider. If that worsens anyway then that equates with more likelihood of them going down pace and ablate route.
It's obviously an option I'll take if I need it but not a first choice as it permanently takes out your hearts ability to function (pace) for itself. Hence I (and the EP) persevered with 3 ablations against the odds. And tried multiple meds.
Hope that helps.
I feel for you. Going through 3 failed ablations and drugs as I also did makes one desperate to make it stop. You will figure it out. Even though you are young, better technology. It really is about QOL
quite a number of people have the pacemaker implanted and that improves things to the extent that the av node ablation is not done
I don’t think I’m one of the lucky one, PM since 28/07/23 but not improvement at this stage. Or, perhaps that is the reason my EP had "forgotten" to tell the nurse to book me in? Must be waiting the result of the PM implant
Today, I agree with you, but there was a time I said, absolutely not. I have had it done and I have quality of life for the most part. That being said it is not a walk in the park and yes, I worry because anything that is a machine can break down. I think of my pacemaker as a very expensive toaster or vacuum cleaner lol my doctor agrees with me about not trusting anything 100% that’s why those of us with a fib has to take ownership of our health and if you question some thing enough, then talk to your doctor and question him in a nice way of course. I had a scare with my pm a few months back. Because I did not read an article thoroughly, I really freaked myself out. My battery life had dropped six years within a matter of hours, according to my app, which I have for my pacemaker. I had everyone nervous because my pacemaker set up is so high tech that until the engineer discussed it with us, everyone thought it lost six years. That being said, there was an issue a year or so ago, where the batteries were cracking and there was no way to know until it happened. I have two back up lines but they still rely on the battery so when your source of power is gone it’s like running out of gas and having no electric around you when you have a car that runs on both, so what do you do?
Because my body rejected everything tried and in a short amount of time I was exhausted physically, and mentally from the failures. That is why I would’ve chosen pacemaker the very first time because hindsight is wonderful lol.
If you read the stories on this site, however you will see there are people that had success with ablations and medications etc. if you can limit your number of events of afib, with something else you should dance with joy. There is no cure everyone and is different. What if you are one of the lucky ones? As good as I can feel I will tell you there are times I feel horrible still. You will also still feel your afib or flutter. The difference is they will no longer damage your heart because the pacemaker is in charge but they still feel horrible. Recently, I had about a week of heavy flutter. My a fib is gone but I also noticed that when I get stressed my flutter will act up or when I eat ice cream. It’s like flipping a coin. if a person ends up like me where nothing else worked within a short amount of time (for me that was left son two years to the point where I could not walk) then don’t be afraid of getting a pacemaker and AV node ablation I also say, don’t have dozens of procedures. My EP will not keep doing things that fail. That is why I ended up with the pacemaker. Three ablations besides, the AV node, I don’t know how many different meds and two cardioversions were enough for him to say let’s move on and get you better. Giving you quality of life is all that they can do no matter what they use. With the scarring and trauma from ablations he said my heart, and I had enough.
if you had a crystal ball and could see how your particular situation would be then I would say get the pacemaker if it was like me because I spent most of my time in tachycardia and ended up with heart failure before I found this wonderful Doctor.
You know what they say if it sounds too good to be true, it probably is. If you talked to me right after my p.m. procedure. I would have told you it was the only way to go. Unfortunately, it was much too early for me to say that as I learned. I’ve been told it could take up to a year for me to be properly healed and I only had this done in February so as you can see, I’m still learning. Getting a pacemaker to me is still surgery. I don’t care what they want to call it and I think anything to do with the heart should be called surgery not a procedure. It’s not like getting a tooth out. I have been under GA so much that to get anything else done my EP has told me not to think about having anything else done before after the beginning of next year unless it is an emergency situation I was supposed to have back surgery two years ago and I also have extensive dental that needs to be done under GA also still on hold. Again, your body can only take so much. Between ablations number one and two I almost forgot I had afib. That’s what you want and you want the easiest way to get there. Best of luck in whatever you end up with. Sorry for the novel, but I’m trying to share what I have learned so people can be prepared instead of being frightened by something I did not know I would still feel anything after I had a pacemaker, so my flutter scared me. I thought something was wrong. I also noticed many times on here people have an ablation or cardioversion, and for some reason they think they are cured. I hate to burst bubbles but I think people need to know the truth. I had 3 1/2 weeks of heaven after my first cardioversion and then one day I was back with a fib and flutter atypical flutter. FYI. No one can tell you when that will happen. It just does. Just like when I woke up from the cardioversion, I was smiling before I even knew how it went then again, it may have been the cocktail and GA lol but when I looked at the Monitor, I had 82 for heart rate instead of over 150 for the first time in a very long time without a break. As afraid as I was of the cardioversion again if I knew and thanks to people in here I wasn’t quite as afraid about getting a cardioversion. It was worth it 3 1/2 of feeling human again.
I think a fib should be better acknowledged and people educated about it. I never really heard of it until my first event when I woke up on the floor. Even then it was neurological that was first checked because I had hit my head several times blacking out twice. Not long after, I campaign started on television called NO TIME TO WAIT. Telling you symptoms and telling you to get to the doctor or hospital. You can still find out about that campaign on line. FYI. If I had seen that maybe I would’ve called 911 that night when I was conscious for a while before I blacked out again. I was home alone and put myself to bed instead and I consider myself blessed. I woke the next day.
I am thankful I found this site and people like Bob and the other incredible people I have made friends with here. They are my teachers along with my body.
Thanks so much for your time and considered reply.
Thank to this forum we are not alone we have each other. The only thing is people need to remember some things need to be addressed to your doctor ASAP. My doctor is a teacher of his specialty anyway and he actually takes the time to teach me. It’s amazing what I have learned from him and I find it interesting of course because it’s about my body. He also does it in Laymans terms, which is even better, because then I can try to share it with others. There is a middle ground that we need to find for ourselves. You want to be hopeful and try things but most of all you want to get a break from a fib because that is the most you can get right now no matter what they do to us. In someways I was a bit like a guinea pig but I had no other choices really and I didn’t realize it at the time anyway lol my doctor kept telling me I was special I thought he was being funny ha ha I should’ve known better surgeons are very really funny. 🤡 don’t give up hope and if you do need a pacemaker, they have amazing things coming out every day. The one that I have has something called HIS paste bundling don’t ask me to explain it. Lol it is new and improved. The pacemaker I have is dual and what’s really amazing is the app on my phone. I am monitored 24 seven and they can transmit from my pacemaker to check on me anytime they want no matter where I am. In fact, they do it periodically anyway.Call them and then transmit one to them with a finger touch to the app. It is Bluetooth connected.
it’s interesting when you’re learning isn’t it? Take care.
Yes to all of that! Thanks so much for your informed reply and all the best.
AF should be better acknowledged and people educated about it. This! Thank goodness for this forum.
Like others here i have been given a PM with intention of node ablation after but the ablation seems now unnecesary. I still get large thump palpitations most days but just a few and i have gotten used to them. I only take blood thinner Rivaroxaban and Diltiazem now which i tolerate well now.
Having read all the wonderfull advice and on the original question 'Why is P&A called the last resort'. Mainly because there's no going back once it's done. However the benefits as far as I am concerned have been great. I waited like you as long as I could through the long time of painful PAF taking all the various medications and procedures ect I took the pace and ablate way. I know that I still would have AF but I feel nothing now and l can look forward and plan things for the first time in 15 years and that is worth the other risks at my age as time marches on so quickly. Best of wishes to you however you decide.
Hi
Pace and Ablate.
I understand it is offered when BP / or H/R are too low.
Which happens when Ablations needed to control/lose AF produce the low scenario and there is no going back.
One of our members only had the Pacemaker. and not both.
cheri JOY
Also when it is too fast. I had tachycardia on a constant basis, as well as both ventricles out of rhythm, and my left atria and a few other things. The new pacemakers can be geared for the individual like mine was it is still not common, but they are learning out there. A hospital in Dallas, where my doctor presented my case, then invited him to teach the EPs there so that they could also help people like me, or I should say, save because my future was very bleak if he had not created what he did for me. I also got heart failure which was progressing rapidly. It has now turned around and my ejection rate is 76 now which my doctor was thrilled about because it’s better than average which is in the 50s. The number one thing is our hearts need rest from struggling with being out of rhythm and our circulation needs to be restored because you don’t realize how much everything in the body needs it until you don’t have it.
Not true. P&A is offered when no other treatment has been affective and quality of life is compromised. As Dawn say modern pacemakers are also fitted to control synchronisation, AF and tachycardia. They are expensive - about 3-4 times the cost of a 2 lead pacemaker which controls bradycardia.
Hi
I was under the hospital then 1 year 5 months later a public hospital outpatients cardiac specialist who left me on Bisoprolol with 156 bpm Day.
It was controlled finally with CCB Diltiazem. The long time with high H/R probably caused my enlarged back chamber heart.
What would happen to me with no control. I wouldn't have been OK to have the removed of Johnson & J TVT Mesh lit.
A Pacemaker?
I have read plenty of those who have had ablations including a friend who now have too low BP. Still ringing A&E in emergency.
I do believe that trying all sorts of meds are not done but an ablation is done, then problems of low levels show.
As Dawn says she was left uncontrolled and then it was shown that damage to her heart was found.
At least I got relief when asleep that my H/R drops down to 47 avge at night. 3 x 24hr heart monitors showed this. Always had cold shoulders at night.
In my opinion ablations are done too early when someone is diagnosed with AF.
cheri JOY
At 73 after 18 years of AFib. 3 ablations and 2 cardioversions and lots of medication my Ep suggested it may be time to have a pace and ablate procedure. I had the procedure in March of this year and my quality of life is back! Honestly during the first few months I was sore and a bit nervous having a device in my chest but after six months I’m so thankful that I can make plans and not worry about having an AFib episode. I’m a grandma of 5 and I’m grateful everyday that I’m able to go to hockey games, baseball games and vacations without fear! To me this is the greatest part for me , I no longer have those days of being in bed with my heart pounding and horrible dizziness. Good luck to all who are contemplating this procedure . I totally understand your concerns as I had them too.
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