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AV Node Ablation
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AV Node Ablation


Posted by Ann Ibrahim on May 28, 1999 at 09:47:26
Thank you for your reply to my question relating to AV Node ablation and implantation of pacemaker for inappropriate sinus tachycardia. Your comments were very reassuring. I have since been informed however that there is another condition with similar symptoms to IST , its called Orthostatic Intolerance or POTS. How could these conditions be differentiated? I want to be sure that I have not been misdiagnosed before I go ahead and have my AV node ablated! For years now my only symptom has been tachycardia, 190 bpm with the absolute minimum of exertion. However I do often have a raised resting pulse of between 100-120 despite beta blockers. Recent symptoms which developed over the past few months include visual disturbances, throbbing headache and dizzyness upon standing(occasionally). My doctor has put these symptoms down to an increase in medication as my BP was up a bit and I was prescribed Irbesartn  (ace inhibitor).
An EPS and sinus node modification were carried out in February but symptoms still persist. My electophysiologist wants me off beta blockers sooner rather than later  because of the effects they have on my breathing (I'm asthmatic). The ablation is scheduled for 7 July at the Royal Brompton Hospital , London. What if this condition is POTs ? Would I still need the ablation to control the tachycardia when the beta blockers are withdrawn? No other drugs control the arrythmia, this is the major problem.
Thank you so much for your help. You all do such a wonderful job!!

Posted by CCF CARDIO MD - CRC on May 28, 1999 at 13:16:50
Dear Ann,
The test of choice for the diagnosis of POTS is a tilt table test.  However it dosen't sound to me as if this is what you have.  the increased heart rate with POTS is only at the same time as the decreased blood pressure.  I would suggest discussing it with your doctor before proceeding with the ablation.
I hope you find this information useful.  Information provided in the heart forum is for general purposes only.  Only your physician can provide specific diagnoses and therapies.  Please feel free to write back with additional questions.
If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter.  The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.
Posted by Dorothy on May 30, 1999 at 19:54:40
Dear Doctor,
Just to let you know, I am a pots sufferer.  The majority of pots patients do not have a decline in blood pressure with the rapid heart rates.  This is why so many people have a hard time finding the correct diagnosis as so few physicians know that this is one of the halmarks of this disorder.  
Posted by CCF CARDIO MD - CRC on June 01, 1999 at 10:30:57

Dear Dorothy,
Thanks for the correction.  Here is a good article detailing the diagnosis of POTS.
Authors
Grubb BP. Kosinski DJ. Boehm K. Kip K.
Title
The postural orthostatic tachycardia
syndrome: a neurocardiogenic variant identified during
head-up tilt table testing.
Source
Pacing & Clinical Electrophysiology. 20(9 Pt 1):2205-12, 1997 Sep.
Abstract
Head upright tilt table testing has emerged as an accepted modality for identifying an individual's predisposition to episodes of autonomically mediated hypotension and bradycardia that are sufficiently profound so that transient loss of consciousness ensues (neurocardiogenic syncope). However it has also become apparent that less dramatic falls in blood pressure, while not sufficient to cause full syncope, may produce symptoms such as near syncope, vertigo, dizziness, and TIA-like episodes. We have identified a subgroup of individuals with a mild form of autonomic dysfunction with symptoms of postural tachycardia and lightheadedness, disabling fatigue, exercise intolerance, dizziness, and near syncope. During baseline tilt table testing these patients demonstrated a heart rate increase of > or = 30 beats/min (or a maximum heart rate of 120 beats/min) within the first 10 minutes upright (unassociated with profound hypotension), which reproduced their symptom complex. In addition these patients exhibit an exaggerated response to isoproterenol infusions. Similar observations have been made by others who have dubbed this entity the Postural Orthostatic Tachycardia Syndrome (POTS). We conclude that POTS represents a mild (and potentially treatable) from of autonomic dysfunction that can be readily diagnosed during head upright tilt table testing.

I hope you find this information useful.  Information provided in the heart forum is for general purposes only.  Only your physician can provide specific diagnoses and therapies.  Please feel free to write back with additional questions.
If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter.  The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.
Posted by Dee on June 01, 1999 at 13:23:43
Hi Dr. CRC,
Hope all is well with you.  I'm doing GREAT!  Hey, I see Dr. Grubb and he is wonderful.  I have the tachycardia problem with the proper response to blood pressure, it elevates.
I'm going today for a 24-hour uptake and tomorrow for radioactive iodine treatment to destroy my Thyroid as I keep having bouts of painless Subacute Thyroiditis, which causes me to go between Hyper and Hypothyroid.  I've had 3 attacks in the past couple of years and it takes approximately 3 months for my Thyroid to get back to normal.  Endocrinologist and cardiologist agree it is best to destroy the beast since Thyroid hormone replacement is pretty much down to a science.  I'm really hoping this will take care of a lot of my tachycardia problems.
It has been an adventure trying to find out what is causing what.  Dr. Grubb says I have a mild form of POTS, but also categorizes people with a beta-adrenergic hypersensitivity problem as a form of POTS.
During my tilt test, my heart rate got a little higher (168), but my blood pressure elevated to 140/90/95ish.  He was happy to see that at least my brain and heart were communicating correctly in that aspect.
There is a web site that Ann can visit that gives information about POTS and also has a forum for POTS sufferers.  I've never posted on there, but sometimes read to see similarities.  Here is the URL Ann:
http://www.ndrf.org
Don't give up Ann, hopefully they will get you straightened around soon.  I can obviously only speak for my experiences, but I've been VERY happy with the doctors I've dealt with.  Good luck!!!
Dee

Posted by CCF CARDIO MD - CRC on June 02, 1999 at 10:26:35
Dear Dee,
Thanks for the update.  Gald to hear you are doing so well.  Dr. Grubb is a nationaly recognized physician in this area and I would highly recommend him to anyone with difficulties in this area.  Thanks for the URL.  Keep in touch.
CRC

Posted by Dee on June 13, 1999 at 19:27:27
You're welcome for the update and URL.  I'm almost back to my normal self here, it is a little scary.  I had my Thyroid destroyed the week before last, so I'm optimistic I will be 100% again in a couple of months.  That is, if I don't grow a second head from from the radioactive iodine :-)
I will keep in touch, you're my favorite CCF doctor!
Take good care of yourself and ta ta for now.
Dee
;-)

Posted by CCF CARDIO MD - CRC on June 14, 1999 at 16:23:41
TTFN

Posted by Dee on June 18, 1999 at 13:53:53
Hi Dr. CRC,
I am a little concerned and have a call into the cardio, but would like your opinion.  For the past four days, I have been having a high low number for my blood pressure.  It has always been normal, so I don't know if it is related to the Thyroid destruction or what.  I seem to get reading ranging from 125/101 to 155/108.  I know the top number is high sometimes too.
When I get on my air dyne to work out, I will pedal for a couple of minutes and my heart rate will be 118 and my blood pressure 140/108.  It never used to do that.  The Endocrinologist warned me before the radioactive iodine that there is a possibility I could go hyperthyroid again.  My heart rates, well other than when I try to work out, have been in the 80s.  Could this sudden rise in blood pressure be caused by being hyperthyroid or be thyroid related?  When I was hyperthyroid before, my heart rate was high, but my bottom number wasn't anywhere near that number.
I'm on 25mg of Tenormin per day, 12.5 in morning and 12.5 in evening.  Any ideas?
Thanks,
Dee
Posted by CCF CARDIO MD - CRC  on June 22, 1999 at 17:19:44
It sounds very suspect for hyperthyroidism. Your doctor may have you increase your tenormin to 25 mg twice a day. Have you ever calibrated your blood pressure cuff?
I hope you find this information useful. Information provided in the heart forum is for general purposes only. Only your physician can provide specific diagnoses and therapies. Please feel free to write back with additional questions.
If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter. The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.
Posted by Dee on July 03, 1999 at 18:11:30
Hi Dr. CRC,
Thanks for your reply.  Yes, I have calibrated it.  We also have a medical department at work and they confirmed the high reading.  It was 125/101 when they took it.
As for increasing the Tenormin, they are afraid to do that because of dizziness problems I was experiencing in May.  This was the reason they decreased it at that time.  They told me to try to ride it out with the Thyroid treatment.  I spoke with my Endocrinologist and he told me I could be Hyperthyroid for a week or two during the process.  When I was Hyperthyroid before, I would get high heart rates, but my Diastolic pressure was always within the normal range.  The Systolic would elevate, but this is the reverse and I really don't like it that much.  It has been much better the past week, so I'm relieved.  Also, my heart rates are hitting an all time low for me since my ablation (60 bpm), woooooohooooo.  I know this isn't anything to be excited about, but it is for me since I have had high heart rates since the day of my ablation.  The Thyroid has  probably been the culprit since that time.  I mean, there was no doubt I needed the ablation, but I'm convinced I will be great in a few more weeks.
I've been vacationing a lot this summer and have been having such a great time.  I really feel like my old self and it is wonderful.  I can't express how thankful I am for the doctors (Dr. Morady and Dr. Kaplan) fixing me up once again.  Before May, the past year wasn't fun at all, but all is in the past (hopefully).  Time will tell, that's for sure.
I hope you are enjoying the nice summer so far.  Hey, I even made it to the flats there (Shooters) and had a lot of fun.  That is a fun place to hang out in Cleveland I think.  We did that during a trip to Sea World.  I haven't been there in about 15 years and think I'm set for another 15 years, that's for sure.  Anyway, I will keep in touch.  Hey, I see Dr. JMF has replaced Dr. MTR or Dr. APS.  You will continue to be on the forum won't you or will you be moving on to other things as well?  If so, thanks so much for your help and good luck in your new endeavors :-)  You've been a great help to me ;-)
I have to go in-line skating now and enjoy myself more!!!  I finished my Master's Program project on Monday and I'm yucking it up, alcohol free of course.  It is really nice to have time for myself once again.
Ta ta for now,
Dee

Posted by CCF CARDIO MD - CRC on July 08, 1999 at 10:21:58
Had a great 4th despite record setting temperature.  APS has gone into private practice in Philadelphia area and MTR has gone to be on the faculty at Duke University.  I'll be here for the forseeable future.  Take care.
CRC

Posted by Dee on July 09, 1999 at 19:41:08
Excellent, I'm glad you are remaining here for a while.  Good for Dr. APS and Dr. MTR.
Oh my, it sure was a scorcher for the 4th.  I thoroughly enjoyed the fireworks and the time off work, that's for sure.  The hydro boats are running this weekend (in Detroit), so that's where I will cook myself.
Take care and talk (well, e-mail) to you soon.
My crony in the UK had his ablation done today.  It seems as if they went in through his groin and his neck.  I guess they had to go to the left side of his heart.  Is this common to go through both locations?  Also, they weren't going to reproduce his arrhythmia, just ablate because they knew what was causing his problem.  They also told him he would know within 48 hours if it was taken care of.  This all sounded a little odd to me, but they are the experts.  Can they really tell in that short amount of time if it is "cured"?
Thanks,
Dee

Posted by CCF CARDIO MD - CRC on July 12, 1999 at 11:33:11
Left sided ablations are not the norm but are not that uncommon.  I gnerally will wait a month or two before declaring complete success.
I hope you find this information useful.  Information provided in the heart forum is for general purposes only.  Only your physician can provide specific diagnoses and therapies.  Please feel free to write back with additional questions.
If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter.  The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.


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