Non-sustained VT episodes post MVR/RF ablation for SVT/CRT-P

Watchful waiting ?

by Gemita - 2021-02-02 04:38:20

Your statement:  “I am nervous because my EP says my sustained sinus tachycardia is an indicator that my HFrEF (heart failure with reduced ejection fraction) is getting worse instead of better which was the goal of the MVR (mitral valve replacement)" is I believe a questionable statement?  I believe your sustained sinus tachycardia (albeit at lowish rates if I recall correctly?) may also be due to the stress from implant/ablation/MVR surgery rather than worsening EF (ejection fraction) alone. Sustained VT (Ventricular Tachycardia) would obviously be dangerous, but I believe so far your VT episodes are self limiting (non sustained)?

Walking in the dark?  Oh the problem of electrical disturbances as I well know.. They cannot give us the whole picture because with arrhythmias does anyone really know Asully how they will progress?  I am afraid in medicine there is always the wait and see element.  It is called watchful waiting and is used for many conditions and can be the best policy rather than rushing in with a sledgehammer to fix a problem that may settle on its own.  They are only asking you to wait until your next echo, by which time an improvement in your EF may well be seen.

I am reassured that an episode of your NSVT was not noticed by you even though it was picked up by your pacemaker.  When I get runs of NSVT I certainly feel them.  Runs of NSVT can be very common for many of us.  I certainly get them because of my SVT.  It could be once your heart has healed following your ablation for SVT (allow a good three months for healing), your NSVT will ease or stop completely, but in the meantime please do not stress an already stressed heart.

Asully, I am angry too for you but my immediate reaction is try not to upset yourself further while you work out what to do for the best because this will only make your arrhythmias worse.  Looking at what has happened I am not altogether surprised that you are having the symptoms you describe, particularly after an ablation when symptoms may get worse in the first few months before they get better (the blanking period) which we have already mentioned in earlier posts.  This is well known and you need to be reminded.  Sorry.  Your HFrEF (heart failure with reduced ejection fraction) will not be helping and will be fuel for your arrhythmias also, particularly your NSVT.  

Yes, I tend to agree maybe in hindsight a bad move not to have gone with the CRT-D but who could have predicted the outcome and after an ablation things can often worsen before they improve, so this might still all settle.  As those of us who suffer from arrhythmias well know, no one can predict the future and how our arrhythmias will behave, but one thing I do know is that after any stressful event (and you have had plenty of them) we can expect a worsening of our symptoms BEFORE they get better.  Yes I know it is not what you want to hear.  After my pacemaker implant worsening arrhythmias were triggered, arrhythmias that I never thought I had, including NSVT (non sustained VT) and this is still happening today but episodes are now very well controlled with low dose Bisoprolol, so I am reassured.  I have not been offered a defibrillator for my NSVT - I know they are not concerned since episodes so far have always stopped on their own.  I note you have hypotension also (like me) and low dose Bisoprolol suits me well and calms any tachycardia, without crashing my blood pressure.  It may be that that is all you need too, to calm everything down?

In your case, I would have confidence that CRT will make a difference but expect to wait a few months to see results.  If say in March no improvements are seen, then you can act with confidence.  

We are where we are and now we have got to try to calm those arrhythmias to protect your heart.  That is the best solution because any further intervention right now would put extra strain on you and just make matters worse.  And in any event we have to allow a period of recovery from both the ablation, MVR (mitral valve replacement) and to allow your CRT device time to make a difference.  If however you have lost complete confidence in your EP and his team, then that is a different matter, but I would still allow a period of calm before you take any action to find a new doctor.  Your body needs it.  There I have had my rant too. 

By the way, do you know what your EF is at the moment?  You know I wish you well whatever you decide to do.

Don’t know my current EF

by asully - 2021-02-02 15:15:50

I was at about 35 before MVR, this will be my first post op echo.  The medicine she is testing on me is ivabradine, I am just waiting for insurance approval to pick it up.  I asked the EP if my new symptoms could be due to the ablation and she said no, that they would have already resolved, which is when she said it is either from the MVR surgery itself or worsening HFrEF.  Either way I hope I can tolerate this new medication and get my HR down.

Ivabradine

by Gemita - 2021-02-02 16:29:18

Asully, I hope the new heart failure med helps to lower heart rate and preserve your EF.  Have you tried anything else, like a low dose beta blocker on its own?  How high is your heart rate?  I recall it was in the 110 bpm range, although it did get higher.  I hope they give you the lowest possible dose to make a difference without it affecting you.

I still believe the trauma of all your combined surgeries:  CRT implant, ablation and MVR has contributed to your difficulties with your worsening HFrEF and new arrhythmias.   You have been through so much.  Good luck with your new med and I hope it helps to control your sinus tachycardia, seems to be a good med for this, perhaps without some of the side effects of beta blockers or calcium channel blockers.

At least 5 BB trials, digoxin, also have adverse from ARBs ACE inhibitors etc.

by asully - 2021-02-02 17:25:15

I have I believe 7 CYP450 genetic polymorphisms and one other genetic mutation that affects drug metabolism.  Many drugs either aren't metabolized at all, or are metabolized to fast, some get broken down into the metabolite that doesn't have the therapeutic effects but has the side effects.  This is why I have so many problems with gold standard guideline directed medical therapy.  This new one falls under one of my mutations where I rapid metabolize unfortunately but we will see how it goes.

Been reading up on NSVT and VT in HFrEF patients found a good article:

https://www.intechopen.com/books/practical-applications-of-electrocardiogram/ventricular-tachycardia-and-heart-failure

Also...

by asully - 2021-02-02 17:31:32

I am symptomatic, I have just gotten accustomed to the whole "there goes my heart goes my heart again" so to me it's "normal".  I only note full syncope, trouble breathing, hypoxia, extreme chest pain, or if I get a HR above 180.  In those cases I seek urgent care otherwise I just ride it out and wait for my next outpatient.  I have been told this is fine by my cardiologists because if I went running to the ER every time I was symptomatic I would never leave lmao.  I am still on almost full bed rest from the tachycardia in order to keep it below 120bpm, my RHR is averaging between 110-130 and dips to between 95-105 about 10 percent of the time.

I hope you get some better results very soon

by Gemita - 2021-02-03 13:46:55

Asully, yes I have learnt to ride it out at home too because I would just push my heart rate up even further by calling an ambulance or trying to reach A&E/ER on my own during a routine tachy arrhythmia episode.  I know my arrhythmias so well now and I know when I am experiencing something really significant.  Of course I do not have your low EF to cope with, so I think you are dealing with your problems exceedingly well.  Yes I can usually tell when my heart rate is above or close to 180 bpm from my symptoms.  The last time it happened was when we were out and it was frightening and I was very close to collapse.  I should have called an ambulance.

I have read your article on VT.  Some of it is frightening, but we mustn’t read too much into any of this because we are all individual and our hearts will respond differently to traumatic events.  My autonomic nervous system can really take off in response to any excitement, both good and bad and I have no control over blood pressure/heart rate sometimes whatever they do to try to help me, that is why I am so afraid of an ablation.  I really think my heart would punish me however good the EP was at doing his job.  I might trust him, but not myself, not my reaction to an ablation. 

You sound as though you have your own set of difficulties that affects drug metabolism.  That must be tricky to handle.  Hubby has had extensive bowel surgery and they often have to give him meds intravenously to be fully effective, since oral meds do not stay in his system long enough.  It is complex like you but sometimes the only way to get on top of an infection, is to get him admitted to hospital for IV fluids/antibiotics.

I can see you have tried quite a few meds.  I didn’t do well on Digoxin.  I have never taken ARBs or ACE Inhibitors but my husband has, but they weren’t successful at reducing his blood pressure.  Beta blocker Bisoprolol low dose I am completely okay with.  I see you have trialled 5 beta blockers.

Hopefully this difficult period will pass Asully and you will soon see the results of your CRT.  Surely it can only get better from now on?  Please let me know how you manage on Ivabradine.

Ivabradine fail...

by asully - 2021-02-22 01:23:16

Ivabradine has failed to lower my tachycardia, some days possibly 5-10bpm but not enough of constant enough to do much good.  Got a referral to a new EP and advanced HF guys agreed to try amiodarone for me, hopefully this week.  Also echo results are back, not good.  EF at 28 now...I just got the results tonight expecting I will be getting a call tomorrow from HF clinic.