My sister-in-law has had paroxysmal AF for a number of years with episodes very short and far apart. Recently, she has had one episode a month for the last three months with the the most recent one lasting a day and going to 170 beats per minute.
She has been told by her EP that if she were to have an ablation, it would not last especially since she is 82. Alternatively, since "her heart rate went too high" she could get a paceamaker and have her AV node ablated (not the sinus node).
She was placed on Metoprolol when she went to emergency at 170 beats per minute, but her EP offered neither another rate control drug nor an anti-arrhythmic drug. Her body cannot tolerate the beta blocker.
Any thoughts or experiences would be greatly appreciated.
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cuore
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Pace & Ablate would be my choice. Pacemaker is implanted under local anaesthetic, usually as a day case, procedure 1-2 hours. About 6 weeks later the AV node is ablated leaving one pacemaker dependent but with a regular pulse although AF may continue. In my opinion it’s a much better option than drugs, none of which I could tolerate.
It sounds quite a radical option but it can give much improved quality of life.
My neighbour's sister is the same age as your relative and had a PM fitted a couple of years ago for her increasingly frequent fast AF and after a while of settling in, she is far better in her health now and seems very well and pleased with her treatment. She, too, couldn't tolerate drugs or at least refused those she considered "too dangerous" (she meant sototalol and flecainide).
I do tend to give a lot of credence to a person's doctor than some since there is such a lot of important background that that is always relevant to their decisions. I would ask for another meeting and put some more questions. A PM is far from a first-line part of any arrhythmia treatment protocol, for example, which he or she is bound to be following, so the doctor must have a very well considered reason for wanting to do the node ablation. Her doctor might consider that permanent AF is on its way, perhaps, since that is the natural course of the disease. An elderly friend, now 90, for example, has had permanent AF for many years, and is hardly symptomatic with no treatment except warfarin.
I take only an anticoagulant. It does depend upon the pacemaker and the reason for implant, mine is 3 lead (both ventricles paced) CRT or cardiac resynchronisation therapy. It was implanted in 2018 after 2 ablations which failed to hold the AF and because I couldn’t tolerate any of the meds and stopped my Af from the moment of implant. I was out of options. I seem to remember that I am not alone on this forum receiving this treatment but seems to be not a frequently offered procedure.
The pacemaker was programmed for AF and I have had no further very high heart rates or dipping very low. It was so successful for me that I cancelled the AV node ablation.
It is just starting to become more available and there was an excellent video supported by the AFA - who I think do have an information sheet but it is a very specialist area and I’m not sure all EPs will be competent or experienced in this technique, I know my EP was very particular on who should complete the procedure (at the time he could not because of his own health issues).
Although CRT is usually used for those with HF, it was the view of my EP that untreated I would probably be in HF within 12 months if my AF was left untreated.
It is worth exploring as ablation as an option may work but often AF returns in older people. I was in my early 60’s when 1st ablation, which made things a lot worse, 2nd a few months later which gave me about 3 years AF free.
Whilst I agree that age alone should not exclude ablation as a treatment it will depend upon fitness and general health. Recovery from ablation can also bring it’s own problems such as increase in ectopic burden, which I found more debilitating than AF and recovery time can take some people months.
Is your sister in law in general good health? My mother had a successful ablation at 91 years old. She was in overall good health, other than a persistent AFlutter that she had for the prior five years. She was pretty miserable on Metoprolol and finally decided on an ablation. Her EP said her age was not a problem at all. Unfortunately she passed away two years after the ablation (from a completely separate cause) so we don’t know how long the ablation would have been successful. I would question why the age of 82 is a factor. Particularly since her AF is not persistent or permanent at this point. My own EP told me that a heart beating on its own accord is preferable to a pacemaker. But every patient is unique, and your sister in law may have other issues, cardiac or otherwise, that the EP is considering. It is my opinion also that the drug options are not ideal.
She is in good health. I forgot to mention that the EP said she would still be on drugs even with a pacemaker.
I have a similar viewpoint and did express to her that age should not be a factor and that she was not persistent to take the more radical route. If I have the story correct, the EP is suggesting the pacemaker because her heartbeat went to 170 which he considered high.
I prefer your EP's viewpoint to let the heart beat on its own.
Unless there are other factors not mentioned, age alone should not dissuade her from having an ablation. Many, including myself, have had successful ablation in our 70's and 80's. Especially true since her afib is paroxysmal with a relatively low burden.
Pace and ablate, on the other hand, is usually reserved when other options won't work, which is not the case here. And btw there are other drugs for rate control such as Diltiazem, for those who do not tolerate beta blockers.
I would definitely seek out other ep's for opinions and I think you will find one with a more positive attitude.
After years of AF and trying all the treatments available I was offered amiodarone or Pace and ablate. I had learnt about the side affects with the drug and decided after much deliberation to go for P&A. In 2022 I had the procedures and after six months of my body getting used to a pacemaker running it I am on no medication except for anticoagulant and blood pressure tablets and no AF. Best thing I ever did. Incidentally I was 84 in 2022 so no need to bother about age.
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High heart rate after ablation
High heart rate.
High Heart rate and Heart ablation
Low heart rate 2 months after Pacemaker and AV node ablation 
Resting heart rate
