PV Ablation § Vagally Mediated Atrial Fibrillation

[bingopajama]

I have paroxysmal afib am 44 years old and would like to have a pulmonary vein ablation by Dr. Natale, however I have heard that the success rate is far lower for people with vagallly mediated afib. If I eat at night,(or eat too much) I'm in afib like clockwork.  I take 200 mg daily of tambocor. I wanted to get the answer directly from the source..........is this in fact true! How do my chances success compare with prople with non vagal afib. I am really grateful that the Cleveland Clinic is doing so much for people with atrial fibrillation.

[CCF-M.D.-KE]

Vagally mediated atrial fibrillation:

This variety of atrial fibrillation results from a different mechanism than chronic atrial fibrillation. The stimulus for atrial fibrillation is usually  from a premature atrial contraction (PAC) orginating in the pulmonary veins. Isolating the pulmonary veins electrically is very effective in eliminating this type of atrial fibrillation. However, vagally mediated atrial fibrillation occurs as a result of a short atrial effective refractory period and PV ablation is less effective.  Usually PV ablation is about 80% effective in eliminating atrial fibrillation. However, this success rate is  significantly reduced in patients with vagally mediated atrial fibrillation. There are not many studies looking at this question, I could not find any human studies. This question is best answered  in  consultation with Dr. Natale.


Thanks for your question,


CCF-MD-KE

[vmpaf]

I have vagally-mediated PAF and have had a PV ablation.  I specifically asked this same question of my EP before finally agreeing to the ablation, and was told that it made no difference (which surprised me).  Whilst in hospital the team treating me said that they get a surprisingly high number of patients with vagal symptoms. I won't name the team, but the EP is well respected for ablations.

So far my ablation was successful until the other day when a common flutter broke out, but I have had only one procedure and was expecting to maybe need a 2nd at some time. This will probably be an RA isthmus ablation (which was done before, but may have healed over).

What I can say is that most of the triggers that set me off before (indigestion, eating, bending, lying on the left) all eventually stopped when I had my ablation.  I got a few ectopics while the lesions were healing and a small (1-hr) breakthrough of AF at +4 weeks.  I got the odd 2-3-beat flutter with indigestion. However, I also have my suspicions that a period of very high vagal tone set off this "final" breakthrough of AFL.

Before my ablation I found an abstract: J. Am. Coll. Cardiol. 1997; 29:732 (No.2), Gaita et al, by an Italian team that suggested extra ablation lines in the RA were beneficial with V-M PAF.

I am encouraged by the doctor's answer to the original question in one way, in that it is clear V-M PAF is becoming better recognised.  However, I would also agree that the evidence linking the effectiveness of PVI's in V-M PAF is scant.

Hope this helps, even a little!

[arthur]

I had PAF start up a few years ago (out of the blue).  I am athletic and my PAF would kick in typically with surges in adrenaline due to extreme effort on the playing field.  I also had PAF kick in a couple of times with a cold drink, and digestion.  So, I'm not quite sure if what I had was V-M PAF.  Nonetheless, it was successfully ablated with one procedure at the Univ of Penn. Hospital.  The source of the PAF was determined as one of several PV foci, and the ablation targeted only one of these foci...so I have occassional PACs remaining, which are quite acceptable given that I can now resume my athletic pursuits without worry.  It's been a full two years since the ablation, with no repeat of PAF.

-Arthur