Pace and Ablate

[Franny50]

I am scheduled for a pace and ablate procedure in October. I've been on multiple rhythm control drugs which sooner or later failed, including Tikosyn, had multiple cardiofversions, and one ablation which failed, I'm told because of my huge left atrium; so I wasn't offered any more ablations.

All of the sudden last February the nature of my AF changed noticeably from on and off paroxysmal to constant, and I developed a much higher heart rate. Strangely, the AF is not as burdensome as it was when it was paroxysmal. I'm taking Nadolol, a beta blocker but still have a widely variable high HR.

I might also have a form of heart failure (HF with preserved ejection fraction) but the echocardiogram can't diagnose it when you are in AF, and I'm always in AF. I have asked if I have heart failure, but never get a straight answer. I am still able to walk 2 miles a day, with multiple rest stops, and do some farm work, but my exercise capacity has diminished greatly since I've gone into permenant AF and tachycardia, and I started having noticeable shortness of breath.

Based on collective knowledge, at what point does a pace and ablate become desirable, or inevitable? Is it a possible fix for heart failure? Does it improve exercise capacity? How is the HR adjusted via pacemaker? I'm researching it, but it seems there is some sort of algorithm that the PM uses to adjust HR when you exercise.

It is all very mysterious, and the EP and his staff don't seem to have the time to spare to address all my questions and issues. I hate to get on their bad side, since I see they are already overworked, and they will soon enough be sending scary tubes and wires to my heart.

[etheral]

Have you tried Calcium channel blockers for rate control?

[Franny50 in reply to etheral]

My EP for 10 years seems adamant that I need to stop all meds except for anti-coagulant and get the pace and ablate done ASAP.

But I'm still not 100% sure why....

[CDreamer]

Essential question to ask is what type of Pacemaker, if you get that far. I had CRT cardiac resynchronisation therapy type which helped symptoms to the extent that I then cancelled the AV node ablation. That was 2018 and Pacemakers have come on a pace (excuse pun) so you need to do your research and then ask pertinent questions of your EP. P&A doesn’t stop AF but will regulate your pulse so although your AF may continue, your pulse should then be regular, even if your heart will not be as efficient because of the stretched LA, it should give you a noticeable improvement in symptoms such as SOB and fatigue. At what stage? Depends upon symptoms, age (too young and PM would need to be replaced too often) and the opinion of your EP as to your suitability.

Heart Failure can be diagnosed in different ways and have various causes so it can be a bit chicken and egg - which came first stretched atria or AF? And are there other contributory factors? Which may explain why you don’t get a straight answer.

Head over to the AFA website and research pacemakers and how they help.

[Franny50 in reply to CDreamer]

Appreciate your information. Thank you.

Found this from Dr. Mandrola (Medscape Cardiology)

Electrophysiologists via pace and ablate can improve heart failure.

medscape.com/viewarticle/95...

[Suesouth]

hi, I have the duel lead pacemaker due to a cardiac arrest, set at a low of 50. Not had an ablation as cardiologist says only 70% successful. They wanted to take me off flecainide, but won’t because AF will definately start up again, controlled with drugs and PM at moment, I’ve also got the heart failure with preserved ejection fraction, upper left chamber very large and heart not pumping blood around properly, awaiting another CTCA scan to see if chamber has got any bigger in last two years.!

[Franny50 in reply to Suesouth]

Thanks for your response. The pace and ablate a/v node ablation is a bit different from the pulmonary vein isolation ablation. I am still learning!

[Suesouth in reply to Franny50]

Yes, my cardiologist won’t do the av node- he doesn’t want me to be totally reliant on pacemaker!

[CDreamer]

Third, mechanical rate control then removes the need for high doses of medication, which can be problematic in older patients. Finally, biventricular pacing removes the downside (dyssynchrony) of right ventricular pacing. Biventricular pacing has a track record of improving death rates vs medical therapy. Excellent explanation.

The above reasons - I didn’t tolerate any meds, I have history of very low BP and variable heart rates and exactly why my EP recommended CRT for me explaining that the chances of dyssynchrony found in biventricular pacing which would result in HF in about 12 months. Their view was why wait until you had HF?

I can’t tell you how much it has helped me.

[Franny50 in reply to CDreamer]

Hi again, CDreamer. I asked this some weeks ago, but am still wondering.

How can the CRT biventricular leads control HR when the a/v node is still transmitting chaotic signals from the atria? I thought pace and ablate existed to remove the a/v node's role and turn pacing over to the pacemaker exclusively.

Since you never had the a/v node ablation, do the CRT leads ignore or counteract the AF impulses coming to the ventricles via the a/v node?

I am researching Medtronic pacemakers for AF, but it is like pulling teeth to get much information on the newest types. I believe the pacemaker companies heavily guard their technology. They also reward the EPs financially for using their products it seems. I'm afraid old age has made me a bit cynical.

[CDreamer in reply to Franny50]

CRT actually stopped the AF for me, no chaotic signals to go anywhere. I know it was the PM because I had to have a revision and as soon as the leads were disconnected, wham straight back into AF. I have the very occasional AF episode if I have an infection but the HR is controlled.

[Franny50 in reply to CDreamer]

That is fascinating, but unfortunately they are going to do the pace and ablate on the same day, so I apparently will never have the chance to find out if CRT alone without a/v node ablation will stop my AF.

I understand that P&A is often a bifurcated procedure in other countries, and some hospitals here in U.S. But mostly, in the U.S., they want you in and out of hospital so they can get to the next patient ASAP. Patients are revenue generating units, you know.

[CDreamer in reply to Franny50]

In the UK the procedure is implant of PM - 6 weeks for healing and settling to ensure there is no infection before doing the ablate procedure, not sure I would have been happy to have it go all in one go. That is the main difference between our two health care systems although we seem to be losing our NHS system for chronic care. Both the PM implant and the ablate procedure are day cases so no overnight stays unless there are complications. These days Healthcare is expensive wherever you live but it seems US does make it profitable.

[Franny50 in reply to CDreamer]

Yes indeed. Our U.S. healthcare is now being bought up by Wall Street venture capital, so it is getting more and more rote and impersonal.

Even my EP, whom I've had for 10 years or so, seems to be trapped on the productivity treadmill. He used to be friendly and take time to explain things. He even gave me his personal phone number. But now he has a PA to interact with patients while he does the procedures and trains the next generation of EPs at the local teaching university hospital.

I long for the old days when doctors were more accessible and less stressed themselves.

[Golfer60UK]

Hello Franny, I was in diagnosed AF after passing out on the golf course, which resulted in a pace and ablate. Now two years and no problems so far. The only medication I take for it is apixaban, a blood thinner.

However i became short of breath and after tests was diagnosed with heart failure.

After speaking to the Cardiologist I have been under from he start of my AF, Then maybe a different pacemaker or medication may be required.

Best advice would be see a Cardiologist

I am 79

Best of luck

Dave

[Franny50 in reply to Golfer60UK]

Thanks very much for your reply. You might be interested in the Dr. Mandrola article (above) re: pace and ablate being apparently somewhat helpful for HF.

[Buffafly]

When you say ‘faster’ - what rate? You are very young to have P&A so all options should be tried. I take a form of Diltiazem - calcium channel blocker - but am limited re dose because I have PAF. If your rate is always high, though variable, you should be able to tolerate a higher dose. But if P&A has been offered I guess your medics have tried everything already. Best wishes with getting a whizzy pacemaker!

[Franny50 in reply to Buffafly]

Hi, I wish I was young, but I'm 75, and feeling it these days.

But sure beats the alternative!

[Buffafly in reply to Franny50]

😹 I read too fast! Had in my head you were 50, I’m 79 so a bit nearer the alternative……

[JOY2THEWORLD49]

Hi

I'm one of those AF folk who has rapid and persistent AF. I've had 2 ECHOs 2021 and 2023 regardless of being persistent!

The Stroke Dr and the hospital Cardiac Special ignored my 156 H/Rate on Bisoprolol. Dr up and upped it to 10mg with no control. I was 186 Day on Metoprolol which I said no to. Pauses at night.

But my Night H/Rate is low at 47bpm avg.

A new Locum asked me to to a Private Specialist - Heart. He introduced CCB Diltiazem.

At 180mg Diltiazem AM, it reduced my H/ Rate Day to 51! Night stayed the same.

Twinked to 120mg CD AM, decreased to 88-96 and when I lost 6kg over the next year reduced to 60s.

Bisoprolol 2.5mg was reduced to 2.5mg PM for BP.

So same regime for 2yrs 6 mths so last year I was discharged from outpatients.

My Locum who has had AF says that taking Bisoprolol for 5 years should reduce my severe left atrium dilation. My heart has returned to normal size.

Get the meds as low as possible and personalised for you and the controlling is the main aspect of meds.

cherio JOY. 75. (NZ)

[Franny50 in reply to JOY2THEWORLD49]

Thank you for your reply. I am still trying to gather all the information and research I can find, and especially success stories, about pace and ablate.

[JOY2THEWORLD49 in reply to Franny50]

Hi

That would be the last resort.

Many have the pacemaker without the ablate.

Why would you when you still need to take anti-co.agulant and still meds for control.

Do take care. Knowledge is POWER.

cherio JOY

[jessieMom2]

Hi Fanny I have been on the Tikosin for over a year now and it is working great for me. The crazy thing about my symptoms when I was going into a fib with shortness of breath and no energy at all. I couldn’t hardly go from my bedroom to the front door without sitting down. I kept thinking it was my asthma, causing the shortness of breath, which I still have asthma, of course. since being on the Tikosin no more AFib attacts. I take it just as it was prescribed twice a day never skip it. Good luck with whatever you decide to do. I will be praying for you. I'm 80 now so God and my doctors have been taking good care of me.

[Franny50 in reply to jessieMom2]

Tikosyn was a miracle drug for me for many years, and I was really disappointed when it stopped working. I have heard of people who successfully stayed on it for a decade or more. I'm glad it is working so well for you.