PV foci

[arthur]

I have posted herein in the past, and would like to thank the doctors for their helpful and explanatory commentaries.  I have had a successful rf ablation of a pulmonary vein focus which was found to be responsible for PAF (Marchlinski, UPenn).  Several other PV foci were located which were found responsible for PACs alone, to the extent of 2-6 per minute on bad days.  I am taking tambocor (200 mg/day) to lessen the automaticity of the atria, and this appears to have brought the onset of PACs down to 0-1 per minute on the average.

I understand that the cardiac tissue comprising the sleeve of the PV ostium makes up these foci, in that the cells repeatedly fire off signals, some of which reach the atria and result in a premature depolarization.  I my case, I can actually feel these foci at work, ie, a vibration (or tremor-like) sensation, barely palpable at either the throat or abdomen (when the foci are particularly active)...this occurs often without inducing PACs.  It appears that when I undergo an adrenaline surge (eg, sudden movement, vivid dreams) the foci kick up and some PACs are induced.

I can live with the PACs.  It's the vibrational sensation that's getting to me, often making it difficult to sleep, since they become even more apparent when other physical stimuli are removed.  So my question is:  What mechanism am I cursed with that allows me to feel the constant tremor induced by these PV foci, and is there anything to be done about it?  My cardio has suggested I learn to live with it...which I gather suggests there is no cure, short of ablating every PV focus...which, of course, is not an option considering the risk/benfit of ablations at this stage of the technology.  What about cryoablations (reportedly resulting in far lesser pulmonary vein edema and thrombi)?

Thanks for your forum and your time!

[CCF-M.D.-CRC]

Dear arthur,

Actually our procedure here is to ablate all the PV foci.  We are finding that the risk of PV stenosis/thrombi is low even with this technique.  I have never heard of someone complaining about feeling the foci firing and am somewhat at a loss to explain this.  So it is possible that even after ablating all the foci you may still have these sensations.  If you wish to be considered for a repeat ablation attempt here I would recommend making an appointment with Dr. Natale by calling the number below.  Best wishes.

[ftayl]

Arthur,

I to had an ablation at Univ of Penn by Dr. Francis Marchlinski. Mine was for Atrial Flutter.However, he was unable to ablate the Av- node re-enrty tach.That was also my third ablation . Since then (9/00) I have been on 100 mg of Flecainide(tambacor)2x daily. Just last week it was increase to 150mg ,2x daily. I also take 325 mg of asprin a day. I am still having problems with PAC's (last holter reading showed about 5000 premature atrial ectopic beats) this was the reason for the increase in meds. Marchlinski did mention another ablation attempt for these pac's , but said it would be difficult. Did he indicate to you if these would trigger a problem later on in life. Right now both he and my cardiologist think the best way to go is with the meds. Only problem right now is fatigue and still feeling of PAC's. By the way, I am an active 38 year old mom of two small kids. I would appreciate any input you may have--you seem very knowledgable in this area. Thanks.

[arthur]

I am an active 53 yr old and am very happy that Marchlinski could locate the specific PV focus responsible for my PAF which really only started up in July 99 (during a particularly difficult soccer match).  The ablation was performed last Aug 00.  Although I have been taking tambocor since then, it is only to help avoid the PAC attacks.  At the time of the ablation, he indicated that he left the remaining foci alone in order to minimize possible stenosis and thrombus risk.  His latest comments suggest that sometime in the near future the remaining foci might be treated (I assume he is awaiting technology that has been demonstrated to be safer...his assistants have also mentioned that a procedure aimed at removing PV foci is a lot simpler to perform since there is no need to correlate their activities to AF or other more persistent arrhythmia).

So, I believe that within the next few years (or months) we can revisit these PV foci and seriously consider their ablation.  I did notice that Marchlinksi's group was quite conservative in their application of this rf ablation technology...with the aim to keep side effects to a minimum (which is fine by me).  Having browsed the commentaries in this forum, it is also apparent that other groups are not as conservative.

I know that those PACs are really depressing and I know that they are considered benign...benign obviously meaning "not life threatening."  So I sympathize with all who have to put up with these things until that day when they are deemed treatable.  Tambocor does in fact work quite well at making the atria refractory to outside electrical noise produced by these foci, but results as usual vary.  I did notice that the PACs are less obvious when your blood pressure is reduced (a side effect of tambocor at 200mg/day).

It's great to "run into" a Marchlinksi patient!  I guess the good news is that you got rid of the flutter.  I wish you well.

[Addie]

Hi Arthur and Fytal.

I was diagnosed with PAC's with a holter monitor last month. They started on March 12,2001 to my knowledge. They also did a Stress Echocardiogram.  The Cardio doc told me to live with them
as they were benign and not life threatening.  The Stress Echo is normal.  I did not see the Holter Report but was told it listed "very frequent" PAC's. Thinking back, i use to get a flutter or two that would come and go very infrequently.  Now, they are with me daily and really putting a damper on my life.

I have allergies very bad plus chronic sinusitis that leads into Bronchial problems and then I wheeze, etc. etc.  I also have GERD, (Reflux).  I left a message on the Cardio's Nurse's station and asked if "breathing problems" can cause these PAC's.

Well, she called me back and the doc said Yes, and he has RX'd a drug called Zebeta. 5mg. that I am to cut in half and take 2 1/2 mg twice per day.  But, first they wanted me to check with my pulmonary doc and tell him all this.  Well, he does not have a clue, so the meds are still sitting at the pharmacy.  

Arthur, you mentioned Pulmonary vein as a culprit to your PAC's.
(not sure I am understanding you, here)

I again, was told my the nurse, that these PAC's will not kill anyone but will drive one up the wall.  She sure is right about that.

I am now wondering if there is a relationship to PAC's with chronic respiratory problems (bronchials) and to GERD (Acid Reflux)

Do either of you have these problems also?  
Have either of you tried Zebeta?

What is an ablation?  Is this an out patient procedure and how do they know where to ablate.  

I am in Texas and we do have the Texas Heart Institute here but if an ablation is necessary down the road for me, I will travel to wherever it takes to get the best one for the job.

Thanks so much.

[ftayl]

Hi Macy. An ablation ,in my own experience(I've had 3 of them), is a relatively low risk procedure when done at a very good hospital. Texas Heart Inst. is rated very good. As your cardiologist or EP Dr.(they speciliaze in the electrical workings of the heart)should explain, you are usually admitted the day before completely off any heart meds. The next day, during the procedure , catheters are entered in the veins on both legs in the groin area. You are give meds to make you sleepy, but you are not totally "out". These catheters are then snaked up the veins to the heart, where the EP Dr. will try to locate the arrythmia. Once found, they will stimulate the heart, by injecting meds into the IV which will produce a rapid heart rate. There is always trained nurses and Dr's nearby to calm you, at to make sure everything is OK. Finally, once they have mapped the arrythmia, they will send "energy" to burn or create scar tissue to stop it. This energy is radio-frequency. This causes some discomfort, but is over in a few minutes. After that , its back to your room with sand bags on your thighs for a couple of hours and home the next day. Recovery at home is a few days. The only problem I encountered is that the first two ablations were unsuccessful because they were unable to locate the arrythmia. However,they were  successful on the third attempt. I hope this answered some of your questions.Good luck.

[arthur]

An ablation is the removal or erasure of a thing.  In the case of pulmonary vein foci, the thing referred to is a spot on the pulmonary vein (or nearby) that is very electrically active, sending signals to the immediate vicinity.  The PV system is located at the back of the heart leading up to the atria, and it is at the attachment point that these foci show up (reasons unknown).  So the vicinity includes a good shot at affecting how the atria behave (the left atrium is basically where each heart beat begins its electronic cycle).  Too much electrical noise from such a PV focus results in sporadic premature beats.  These premature beats can be considered heart hiccups...coming and going at their own pace.

Irritation to these foci can increase their activity and result in more premature beats.  This irritation can take the form of physical stress, caffeine, GERD, gas, and any number of odd conditions that can either physically or chemically irk those foci.

Ablations carry with them a risk of complications (generally small, but not zero), which include stenosis of the pulmonary vein (thickening of the wall and constriction of blood flow) and thrombi (clots that can lead to stroke).  That's why doctors tend not to ablate foci which cause no direct harm to the patient (like 90% of those troublesome PACs)...but are willing to consider ablation when a more persistent arrhythmia is caused by them (like atrial fibrillation, flutter, tachycardia...).