AV node ablation with pacemaker

A difficult decision

by Gemita - 2023-01-23 10:24:52

Osprey, firstly welcome.  I am truly sorry to hear about your persistent AF and your fall in ejection fraction (EF).  You certainly need an urgent fix to try to stabilise your heart and I would think you will need both a heart failure doctor as well as an EP to work together in the future, to give you the best possible chance of a good outcome.

Although I have not had an AV Node ablation I was offered this and also Amiodarone as a way forward some years ago, so I researched both treatments extensively.  I chose Flecainide and Digoxin and a pacemaker for tachy/brady syndrome instead.  Have now successfully dropped both anti arrhythmic meds and am only on Bisoprolol for AF episodes with an occasional rapid ventricular response rate but on the whole doing extremely well. 

In your shoes, I would want the over active thyroid treated urgently first because that will only make matters worse.  What to do about the scarring and AF is more difficult.  Do you have confidence in the EP or could you find another EP with more experience in treating difficult AF cases?  

AF would still continue in your atria after an AV Node ablation unfortunately since it is not a cure, but it would be prevented from reaching your ventricles so you should start to feel better quickly, especially if your heart rate cannot be well controlled with rate control medication? Also the irregularity of rhythm would not be felt quite so much since this would also be prevented from passing through your AV Node to affect the ventricles.  

Whatever you decide, what is apparent is your need for urgent treatment to prevent worsening symptoms.  I would want to know if my doctors intended giving me a CRT pacemaker from the outset to give me the best possible chance of supporting my heart to try to prevent any further decline? 

Although final, an AV Node ablation can be helpful when the heart rate cannot be controlled by other means, since a rapid heart rate would push the ventricles too hard and quickly lead to worsening symptoms.  It is a final tool in the cupboard against AF, I know, but it can be the only option remaining if all other treatments have been tried and failed?

I know several members here in the Club and also in my UK hospital who have had an AV Node ablation and most of them are happy with the results, some even saying they wished they had had the procedure years ago.  An AV Node ablation is a short procedure (I was quoted around 20 mins) and is usually always successful, unlike the regular pulmonary vein isolation ablation that may take several attempts to give us the best chance of success.  An AV Node could still be in my future, so I will watch your progress with interest and I wish you all the very best.

Av node ablation

by Osprey1971 - 2023-01-23 11:10:24

Hi Gemita and thanks for your advice.  It is greatly appreciated.  I am from South Wales am happy with my EP but do understand that the bigger more established centres will have EP's with greater experience in treating AF.  I am going for a second opinion to the London AF  centre (Barts). 

I had my overactive thyroid diagnosed in July '22 and immediately came off the Amio.  Stayed in rhythym until Dec '22 then went into AF where I am currently.  Back on the Amio as ablation due a fortnight today.  My EF drops instantly when in AF.  Hoping the ablation will buy me some time to think over my options to be honest.  I feel I'm young to have an av node with pacemaker but Heart Failure is a real worry.  I was hoping my EF would stay at 55% + and would be able to control the AF with medication.

Thanks again Gemita 

Excellent news

by Gemita - 2023-01-23 11:28:08

Barts is a great centre to go to for a second opinion.  I know several members who go there.  I am under Guy's & St. Thomas' Hospital in London.  You need the very best to have the best possible chance of success with AF.

I really hope your next ablation gives lasting results and buys you precious time.  It could be though that your doctors may suggest a pacemaker is in your future, so that they can give higher doses of medication to better control your AF without causing your heart rate to plummet.  This is what my doctors first did for me.  It certainly bought me time and it worked.  I was booked for an AV Node ablation 6 weeks after my implant, but was happily able to cancel the procedure when I saw the favourable results with medication and pacing alone.  

AV ablation

by AgentX86 - 2023-01-23 16:08:02

Osprey, welcome to the club.  Wish you weren't here. Please fill out your bio, it really helps answer your questions.

I have been through much the same path as you, except I also had a Cox maze to get the ball rolling.  I had AF in '07 but after a DCCV it went pretty much underground until '14, when it rose its ugly head again.  I also had a CABG just after than so while they were in there, they did the maze procedure.  That fixed the AF but put me in permanent AFL.

I also took ameoderone which did work it also damaged my thyroid.  My cardiologist wouldn't leave me on it for more than six months at a time because it is so toxic (it's not a matter of if you'll get "these" symptoms, it's when). It still got to my thyroid.  Fortunately, it recovered.

As I said, I had multiple ablations with a different drug between them to try to figure out some combination.  Sotolol worked reasonably well but damaged my SI node so had tachy/Brady as well as sinus pauses.

I clearly needed a pacemaker so it wasn't a large leap to do the AV ablation, too, to get rid of my AFL. Of course it doesn't get rid of anything, just papers it over. It worked very well for me and felt 100% better by the time I got to the recovery room (just local anesthesia so no recovery). It's been five years now (time flies) and I'm still doing well.  As noted in another post, rate response is a RPITA but other than that, I'm doing very well.  I have developed a short bit of chest pressure when walking but it's completely random and only lasts five minutes or less, out of three hours.  My cardiologist just gave me a prescription for low-dose nitrate to see if it helps (day two and it might be worse).

My bottom line is that my AV ablation worked exceedingly well and I'm happy that I did it.  It is a very serious step and should only be considered if you're highly symptomatic and can't function with AF/AFL.  As you note, it's a dead-end street.

I should note that I have a CRT-P pacemaker, which is what you'll probably have since your EF is so low.  I don't have it for that reason (don't really know what reason).

Thanks

by Osprey1971 - 2023-01-24 07:06:50

Thanks Agent appreciate you responding with some great advice.  My EP seems to think amio can be taken for many years.  I'd read some horror stories prior to commencing the loading phase prior to my first ablation but I have to be honest for two years I was fine on the drug. 

I am very hesitant having the AV node if this ablation doesn't hold but see I have no other option.  I will get a secon opinion 100%.  But as soon as my heart goes into AF my EF drops quickly.  I'd be happy to stay in AF if I could control things better with medication as I was asymptomatic.  The amio is not a long term drug so for the benefit of my heart I feel a Pacemaker is the way forward.  

My concern with the AV node is having shortness of breath after the procedure.  At the moment with an EF of 36% I have some SOB and fatigue with swelling in the upper abdomen but am doing ok.  Just completed week 1 of Amio loading phase and although out of rhytym it seems to have helped already.  

It's great to hear you are doing well after your procedure.  And again thanks for responding

AV ABLATION

by lizzie - 2023-01-27 21:49:40

I too had this choice to make back in 1993. I suffered 5yrs of SVT, bradycardia, atrial fibrillation and severe arrhythmia. Episodes of heart going from 60bpm to over 200bpm for 10+ hours multiple times per week. It was a locum dr in the hospital that said it was life threatening and would prescribe Amiodarone (reluctantly owing to potential side effects). However my condition was so severe I required the max dosage to control problem. It was the only drug that had made me feel "normal" in 5yrs Ultimately it resulted in overactive thyroid which was then shrunk with radioactive liquid and I've been on thyroxine ever since. I decided, in order to have any quality of life, to go for the ablation/pacemaker option. So at 39yrs of age my first pacemaker was implanted.  I'm now on No 4 and apart from a bit of a struggle with stairs and hilly inclines I'm still here to tell the tale. Fortunately I never had to take any heart meds after my op. Good luck. 🤞