AV Junctinal Ablation Procedure

AV ablation + pacemaker

by AgentX86 - 2024-04-19 15:05:25

I did, six years ago (amazing that it's been that long).  If you do a search of this site, you'll find a number of us.

It's a very serious decision (though relatively simple and safe procedure) because it will leave you pacemaker dependent for the rest of your life.  Unlike someone with heart block, this is something that you're doing voluntarily.  It's not a necessity.

It's posible that not only will you be dependent of your pacemaker, but your heart won't beat without it.  After destroying the AV node, there is no possibility of a "junctional rhythm".  That removes one of the heart's backup systems. The only one left is the ventricular beat which, if there, is quite possibly not fast enough to maintain consciousness. I know there's a lot of "ifs" here but you have to know the down side of this particular procedure.  It's an elective procedure, which can have serious consequences.

Fortunately, pacemakers are incredibly reliable.  The Achillies heel of pacemakers are the leads. I have a CRT pacemaker (two ventricular leads), so if a lead fails, the other one is enough. That's where I am.  No detectable backup heartbeat but a backup lead.

On the positive side, there is almost a 100% certainty that it will eliminate the symptoms of any atrial arrhythmia. In general, as long as you're antcoagulated, and the heart rate can be held under 100, there is no need for this. The symptoms may be so bad that it's worth it but think about it.

The arrhythmias will still be there, just painted over. That's the way you have to approach this.  Is there any other way to suppress the atrial arrhythmias, at least to where you can live with them?  It's rare that this would need to be done for other than the relief of the symptoms.  Drugs should always be tried first, though if a few are tried without success, we come to the decision, whether suppressing the symptoms is worth the risk. These drugs are certainly not without risk, but drugs are reversible, though perhaps not the damage they cause.

There are also some other, much more minor, issues.  You will be chronotropically incompetent.  The heart's natural pacemaker is no longer useful, so the pacemaker has to do this job.  It often doesn't do a very good job of if.  If you're active, you'll likely have to make tradeoffs in performance. I've been having a lot of trouble in this area, lately.  Everything they've done has made it worse, so I'm back to my original settings and will just deal with it.

Also, the whole idea of the AV ablation is to keep atrial arrhythmias from getting to the ventricles, so do normal heartbeats. There will be a loss of AV synchrony. The aria are there to help fill the ventricals to make them more efficient.  Something like 20% of the heart's output is because of this "supercharging".  I didn't think this was all that important but I'm having second thoughts (discuss with EP and cardiologist next month).

All in all, it's a very serious decision and one you need to have your doctors fully explain and give both sides.  Only then can you make an informed opinions about what's better for you. Your situation may be completely different.

Yes, you will be on drugs the rest of your life.  You will almost certainly be on an anticoagulant (probably Eliquis) and there is a better than even  chance a beta blocker (usually metoprolol).  If you're prescribed an anticoagulant, it's an imperative.  Stroke is an ugly thing, sometimes worse than death and may cause the death of someone else.  Take the anticoagulant religiously!

As I said, I did it six years ago and am glad I did.  I had a weird case with atypical flutter (caused by a procedure to stop Afib) and a slow AV node made it feel like Afib but worse. I had been through most of the antiarrythmic drugs (which caused further damage to the heart and thyroid), and couldn't sleep, so the only way out was an AV ablation.

Bottom line: think hard about this.  Seek the honest advice of your doctors (not Dr. Google, or Dr. PMClub). Get all the information that you can. Then, and only then, make your decision. You only get one chance at this.

. Ver

by Otto 1234 - 2024-04-19 17:07:09

Thank you so much for your quick and honest respone, Agent X86.  Very helpful  The procedure is for my father who is turning 96 next month.  He has tachybradyarrhythmia.  We are hopeful this procedure will improve the quality of his life and give hime more energy.  Both the rate control and rhythm control meds have been difficult for him to tolerate.  I wonder if with the ablation and pacemaker he will tolerate metoprolol better?  Or perhaps a different med will be prescribed.

Perhaps he will be able to reduce or to stop most of his meds

by Gemita - 2024-04-19 17:46:39

Otto, with an AV Node ablation, the fast, slow, irregular rhythms from an atrial tachy or brady-arrhythmia will be unable to get through the AV Node to push the ventricles or to affect them in any way, so your father should be able to reduce or even come off many if not most of his medication.  That is one of the reasons why many patients opt for such a final procedure, especially when they do not tolerate medication or have failed a regular pulmonary vein isolation ablation procedure. The fast, irregular rhythm from say Atrial Fibrillation would then be confined to your father’s upper heart chambers (atria).  He should not feel so symptomatic  anymore because his main pumping chambers (the ventricles) would be isolated from his upper chambers and set to pace him at a steady fixed heart rate.

At 96, I don't think you should expect too much!  I think your father is doing incredibly well to tolerate his diffculties.  The AV node ablation is a simple, short procedure. I am not sure that my team would offer me this treatment at 96, although a pacemaker may well be needed? 

Quality of life

by AgentX86 - 2024-04-19 18:00:54

I surely helped my QOL, but I was only 65 at the time.  I'm pretty active so ask more from my pacemaker than your father is likely to. That part of it should be fine.

I understand the issue with the rhythm conttol meds.  They are all nasty drugs, some much worse than others. At 95, though, anything is on the table.

I doubt that he'll tolarate metoptolol any better but there are many other beta blockers and calcium channel blockers that he might tolerate better. His doctor should be able to come up with something.

If tachy/Brady, is the "only" problem, he may not require anticoagulation but the rate still needs to come down.  After his pacemaker is implanted, there is no risk of slowing the heart too much, so they can agressively treat the tachy, without worring about the Brady.

AV Junctinal Ablation Procedure

by Otto 1234 - 2024-04-19 18:48:04

Thanks again, Agent 86X and also thanks to Gemita.  My father has had a blood clot in his left aortic appendage for several years, so he will definitely have to stay on blood thinners.  The meds are my main concern b/c they have periodically made his life miserable.  It will be great if that is not the case after the procedure!  I appreciate the input.

AV Junctional Ablation Procedure - Update

by Otto 1234 - 2024-05-02 11:17:07

Thanks again for all of the comments.  Last week, my 95 year old father received a Medtronic Azure XT SR single thread pacemaker and had an ablation of the AV node junction.  All went well. His initial HR was set at 85 bpm.  His metaprolol was cut in half from 25 mg to 12.5 mg daily.

He had a one-week f/u yesterday. HR ws reduced to 75 bpm yesterday.  This am my father says he feels more energetic.  His ECG showed vertricular arrhymthia yesterday, so they are keeping him on the beta blocker.  If all goes well, his HR will be reduced to 60 bpm at his 3-month appt.

AV Junctional Ablation Procedure

by Otto 1234 - 2024-05-30 22:57:29

About a month ago, my father received a single thread Medtronic pacemaker and an AV Node ablation.  At first he felt good and had more energy, but after a few days his energy level fell and has stayed low since.  After a week, his HR was set at 75.  It is scheduled to be reduced to 60 after 3 months (end of July).  He continues with a half dose of Metoprolol (12.5mg daily).

He's going to have an aortic valve replacement next week - will that help increase his energy level?  Should we ask EP about lowering his HR sooner?