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Heart Disease  (Expert Forum)
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vagally mediated or mechanical problem
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Cleveland Clinic -
Cleveland - OH
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MedHelp Member's Question

vagally mediated or mechanical problem

by StephPT, Jan 12, 2005 12:00AM
I am a 31 year old female with a structurally normal heart (EKG, ECHO, CT chest and abdomen, and all labwork have been normal) that has been having runs of SVT vs. A-fib vs. A-tach every time I eat.  It occurs with swallowing (food, and some beverages, but not with just swallowing air).  I had 18 episodes during a 24 hour holter monitor, with rates between 180-200 bpm.  These are often accompanied by lightheadededness.  I have tried multiple medications (toprol, toprol plus digoxin, verapamil, flecainide, and norpace with verapamil) with no success.  I have had two attempts at ablations (the most recent was 1/10/05) with no success.  Both times, the EP was unable to induce the arrhythmia on the cath table.  On the first attempt, Isopril was given, with no arrhythmia UNTIL it was turned off, and then I converted to atrial tachycardia, supposedly in the left atrium (he was only prepared to do a right ablation).  During the most recent study, large doses of epinephrine were administered, and with great difficulty, the EP was able to ablate some PACs on the right, but saw nothing on the left, so didn't venture over.  As a last ditch effort, yesterday, he passed an NG tube and jiggled it around (not the most pleasant experience) in an attempt to manipulate my esophagus and induce the arrhythmia, with no luck.



My doctor (in his 14 years of practice) as never seen a case like this.  He has consulted with someone at UPenn, who is also stumped.  My question is:



Could this be vagally mediated, or is it possible that structurally, my esophagus is rubbing my heart with swallowing
Doctor's Answer

by Cleveland Clinic, Jan 12, 2005 12:00AM
steph,



thanks for the post.



It is possible that the arrythmia may be induced by a disturbance in the cross talk between the innervation of the heart and digestive systems.  If it a focal arrythmia, it should be ammenable to ablation.



Clearly this isnt exactly a straight forward case and seeking a second opinion at a tertiary care center should be your next step.  



Good luck





Member Comments (18)

by StephPT, Jan 12, 2005 12:00AM
To: doctor
Also, any suggestions on how to induce the arrhythmia on the cath table, and are there any other tests I should undergo?  Thanks so much for you time!!

by Momto3, Jan 12, 2005 12:00AM
To: StephPT
I had different arrythmias that the type you are having, but I thought I might share something interesting.



When I had my second ablation for frequent pvcs, the doctors were almost certain that the foci was on the right side (EKG).   During the procedure, the pvc was mapped with a catheter using the electroanatomic Carto mapping system and mapping from the right ventricle demonstrated that earliest right ventricular activation was late in comparison to surface ECG, indicating a left-sided origin. In essence, it was a real fooler from all indications. They used calcium chloride to induce ectopics. They also told me that every time they re-started the versed (IV), the ectopic activity would come to a halt. I guess it made for a challenging procedure : )



Apparently, the versed would relax things enough that the ectopics would stop...They told me I could just stay hooked up to the meds and I wouldn't have any pvcs.  BUT, I'd be asleep all day : )



My situation may not be the same as yours, but I figured it was worth sharing my story just in case it could help.

by StephPT, Jan 12, 2005 12:00AM
To: momto3
Thanks for your comments.  I have no doubt that some of the medicines they give you interfere with the heart's ability to produce the dysfunction that haunts us during a normal day.  My NG tube experience is a perfect example.  If this is vagally mediated, there is NO WAY that my parasympathetic nervous system could kick in while someone is jamming a tube down my throat...I was practically clinging to the bedrails!



If the versed caused the ectopics to stop, does that mean that you were awake during the actual ablation?  I bet that was fun!

by arthur, Jan 12, 2005 12:00AM
To: StephPT
About 3-4 years ago, a fellow whose first name is Peter posted a similar complaint, ie, PAF upon swallowing.  He had consulted a bevy of experts, cardiologists and others, to no avail.  As I recall, the closest anyone came to an explanation was that the swallowing reflex is a complicated act involving a number of nerves ... and that somehow the signalling gets confused with an arrhythmia.



Peter has stopped posting, and I really don't know what the final outcome was.  I don't think he tried any ablations.



Having had PAF myself, I spent quite a while researching the condition and the triggers.  Assuming the PAF is a result of a focus located in the left atrium and/or the pulmonary vein ostia, it may be that the electrical activity of a nerve involved in swallowing is near enough to a focus that its activity permits the focal signalling to reach the AV node and disrupt normal rhythm.  This is a hypothesis, since it's a known fact that focal signalling is modulated by the state of the nervous system embedded in the cardiac tissue.  Two different types of signals, one acting like a gate for the other one.



The bottom line is to discover the focus or foci responsible for your PAF...and to do this you need to map that left atrium and PV ostia.  From your description, it is not clear that this was done.



BTW, an article in J. Electrocardiol. 1986 19(2), pp 193-6

describes a patient with a swallowing-induced paroxysmal SVT and the treatment that worked to cure it (surgical ablation).



Perhaps it's time to find a different EP.



-Arthur

by StephPT, Jan 12, 2005 12:00AM
To: Arthur
Thank you sooooo much!  I reviewed the article abstract online, and look forward to getting the entire thing in print.  I found several other, older, articles that discuss the same type of problem.  I will be taking these to my local cardiologist, and I am already exploring the options of another EP at a larger facility (possibly Hopkins).  It is so nice to know that I am not the only person who has experienced this, and that treatment is possible.



Steph

by Momto3, Jan 12, 2005 12:00AM
To: StephPT
You're welcome!  I agree that some of the medicines may interfere with our "irritable" hearts.  Your experience with an NG tube sounds like something I will defintely do my best to avoid.  The whole concept of someone "jamming a tube down my throat" is um, um....NOT!!



Fortunately, the entire group who was responsible for taking care of me in the EP lab KNEW I wanted to be asleep!  They kept introducing the versed and backing off...I don't remember any of the stuff they told me about.  THANK GOD!



Good luck!  Looks like Arthur provided you with a great source of information!

by lmroswell, Jan 12, 2005 12:00AM
Wow, this sounds like what my husband went through a few years back.  The doctors did not believe him when he said his heart raced when he swallowed food or drink.  But, eventually, in the ER, they were able to document an event on an EKG.  He lost 15 pounds in less than 3 weeks, because he was terrified of eating.  Eventually, the problem resolved on its own.  I do not remember what meds he was on.  An EP was recommended, but we waited it out.  I do believe that the vagus nerve was involved in some way, but no firm diagnosis was ever established.  I hope yours resolves soon.

by PVC, Jan 14, 2005 12:00AM
I am the Peter that was refered to in this discussion series.  I just happened to link into this discussion and was surprised to see the reference to my name.   So much (good) has happened over the past 4 years and I would love to share it with you or anyone else that is interested in hearing how I basically went from chronic PAC's, SVT, and LAF to 4 years of normal sinus rhythm.   The main change for me was finding out that I had significant reflux and started taking proton pump inhibitors.   I never suspected that I had the reflux until I asked for a barium swallow because of the 100% correlation between the action of swallowing and the onset of arrythmia.  I have been on the PPI's ever since and have basically remained free of the problem.  I visited the Mayo clinic, had a negative EP study and, like you, had the arrhythmia specialists say they had never heard of such a swallowing connection.  I found many articles that discussed this rare connection.

There is lots more to say but I will wait for contact before doing so.   I do not check this forum often so the best way to start up a discussion is to email me directly at ***@****

Cheers

Peter

by arthur, Jan 18, 2005 12:00AM
To: PVC
Peter,



I do remember you mentioned GERD as a possible source of irritation, and of course, GERD is still considered as a controversial trigger for arrhythmias wihtin this forum.  Regardless, it's great to hear that you are doing well!!!

-Arthur



by TITUS, Jan 25, 2005 12:00AM
When I first started having SVT and PVCs it was always during a meal or after a meal.  I went from one cardiologist to the next.  I had an EP study that did find an abnormal pathway but was in a dangerous location to ablate.  Finally, when I started taking Aciphex, a medicine for acid reflux I improved tremendously.  When I eat salads or hard to digest foods my palpitations get worse but the aciphex helps.  I also take Sectral, the only beta blocker approved for treatment of PVCs.  They even give it to babies and you can regulate the dose.



My EP cardiologist also recommends high doses of magnesium to anyone suffering from heart arrhythmia and is watching clinical studies of flaxoil as well.

by StephPT, Jan 27, 2005 12:00AM
To: titus
Thanks for the info.  I have tried Protonix, even double the dose, and it has done NOTHING for my arrhythmia, although it did a great job on any heartburn I may have had!  There is very little research out there about "deglutition tachycardia" (that's the formal title for this rare condition), but most cases are in the absence of any