Problems Following Ablation

[WPWGuy]

I am 45 yo male in good physical condition. I underwent ablation in April this year after long history of paroximal tachycardia triggered occasionally during jogging and lasting 1-5 minutes per episode. On the day after the procedure, the doctor told me that I had left free wall form of WPW, and that he had successfully ablated it. However, a heart monitor recently showed  PVC's, short burst of SVT, short burst of VT, and something else (looks like it could be AF) not diagnosed yet. At this point I experience a great deal of heart sensations at rest, after ~5 consecutive days of jogging (easy 2.5-3mi run each day). These subside after 2 days of rest.

I have been told that I need an angiogram first to determine the potential source of the VT, and if everything checks out OK, a second "touch up" ablation. I have bought into the angiogram, but am wondering about "the touch up". My questions: 1) should an EP study be performed before the ablation, but after the angiogram; 2) should the angiogram and the ablation and/or EP study be performed by the same medical group or medical center; 3) this seems to be the sort of problem that could warrant taking some steps to find an especially qualified ElectroPhysiologist to help - are there resources you can suggest?

I am reaching the brink at this point.  I am way too analytical and a habitual worrier. Any helpful advice would be appreciated.

[Cleveland Clinic]

wpw

thanks for the post.

1) should an EP study be performed before the ablation, but after the angiogram

VT can be a sign of ischemia. It is not unreasonable to pursue an ischemia evaluation.  If the VT was from blockages in the arteries, an EP study or ablation wouldn't help. This may be why your EP is pursuing this course.

2) should the angiogram and the ablation and/or EP study be performed by the same medical group or medical center

It just depends on your comfort level with your care thus far. There would be nothing wrong with seeking a second opinion and returning to your EP if you trust their descions.

3) this seems to be the sort of problem that could warrant taking some steps to find an especially qualified ElectroPhysiologist to help - are there resources you can suggest?

Any time you have a procedure you want to find an experienced physician to do it or take care of you. Im a firm believer in second opinions. Sometimes a fresh set of eyes can see things in a new way.  It may aslo help with your habitual worries if someone concurs with the care thus far.

good luck

[WPWGuy]

Thanks. I should have mentioned that there was a concealed pathway.

[bigmick]

Hi,

I (male 43yrs 6'4" 225lbs strong structurally normal heart) too have PVCs and PACs (last 20 yrs), have had a documented run of VT (11 beats - 6 yrs ago), and have had 5 short episodes of AF to boot in the last 5 years (all nocturnal, self-converting after 3-ish hrs, no meds). My PVCs are from 2 (or possibly more) focuses.

Your postings have kinda gotten me wondering whether or not I might have a concealed pathway! Or maybe I'm being neurotic. Maybe Pluto will weigh in with his views as a fellow neurotic!!

FWIW, I'm personally convinced that many arrythmias (and certainly my own) start with upper gastric problems such as GERD and esophageal dysmotility. I know that I DEFINATELY get FAR more ectopy/arrythmia when I'm suffering with bad reflux/heartburn/indigestion/esophageal cramping. Could be that the electrical signals within the enteric nervous system get skewed out of kilter and this in turn affects the cardiac tissue either directly via inflammation or indirectly via the vagus nerve. I understand that some Austrian medical researchers have just recently established a strong correlation between GERD and paroxysmal vagally-mediated AF.

BM.

[WPWGuy]

yes, I can relate that exercise and sometimes sudden movements (i can recall a specific volleyball spike 15 years ago) used to set off my tachycardia.

I have never tried drugs for this and probably would have considered their use if things happened differently.  The first documented ECG (April of this year - lasting one minute or more) came off of a heart card I was using and we could not tell whether it was a VT or the WPW variety of PSVT.  So the docs got fairly nervous when I showed em the "heart card" strip. This resulted in an EP study almost instantly!

take care...

[WPWGuy]

BigMick, thanks for your insights.  Shortly after the ablation, I could have sworn that my heart and stomach were connected to the same nerve ending.  I even spent some time trying to find out if the vagas nerve passed to the heart somehow.  Not sure I ever got to the bottom of that one, but the ablation of course took place near the Mitral annulus...

I dont know anything about AF or whether I had AF before.  I do see squiggley lines  on many of the ECG strips that sometimes run all the way from one QRS to the next. Sometimes these preceed a PVC. I also think I see a small delta that preceeds the qrs, and to pluto's point may represent some pre-excitation I didn't use to have. Not sure, but I'll definitely need to ask some questions when I see a doctor here again in a few days.

Thank you both for your ideas.  This little conversation has been very helpful to me.

[wxci]

I was wondering whether any of you who have had ablations could give a brief description of what happens when you go in for the procedure. How long does it take? How do they help you deal with the anxiety? How does the EP find foci? Do you have to have your PVCs or whatever right there while they have you hooked up? Sorry for the tons of questions, but maybe others who read these boards are wondering the same things? Thanks for all your great posts!!

[bigmick]

Fellas,

How does a cardiologist/EP establish whether or not one has a concealed pathway??

BM

[Momto3]

I had two pvc ablations in 2003 and each lasted approximately 6-7 hours. They began with an EPS and resulted in successful RFAs.  I let the nurses know (my doctor already knew!) that I was really nervous and they gave me some "versed" prior to entering the lab. I vaguely remember the lab, but have NO recollection of either of the studies or RFAs. I was told that as long as I was having "some" pvc activity, they were pretty sure they could ablate the foci. They find the foci by mapping the heart's electrical system (EPS) and pinpointing the irritable ares(s).  

Hope that helps.

connie

[dquenzer]

I had an ablation 2/20/2004 for AFIB, PAC's, and atrial flutter.

Thankfully it was very successful.

I went to Mayo.  Had an excellent EP.

I had a 7.5 hour procedure.  I only remember the beginning.  

Actually when they put in the catheter, that's when you should be asked to be given a sedative.  That was the worst.

I did not have anesthesia because they wanted to make sure they could find the foci.  

I woke up 7.5 hours later, my back hurt from being on it that long, and I felt a bit sleepy.  Ask for meds for lower back pain.

Also you have to lie flat for 2 hours so that you don't get any bleeding.

Was up and took my first walk about 3 hours after procedure.

I was sore for about 3 days.  Was back to work 3 days later.

Couple things to keep in mind:
1)  You may have arrythmias following procedure due to irritation of heart.  I did, but they soon subsided after a few weeks.  Sometimes it may take longer.  It takes about 3 months for a confirmation on success.
2)  You will feel a bit tired for a month or so.  It takes a bit out of you.  More than you think.  At least it did me.

At Mayo they had me come in 3 days before procedure for lots of tests to make sure I didn't have any ischemia.  So be prepared to take about 1 week off of any work.

[wxci]

Thanks dquenzer! Exactly what I wanted to know. Some of the doctors I talk to tell me so casually "oh, you can just get an ablation" as if it were just a simple five minute procedue. I hope others who are thinking about ablations read this thread. Very helpful to know exactly what kinds of things would be involved. I still might do it but it helps enormously to be mentally prepared.  Thanks again!!

[jobob52 ford]

Hi Guys, as I recall, the sinus node monitors oxygen in blood and controls pulse rate. It controls pulse rate by controlling signals/impulses to the atria muscles. That same signal goes through the atria muscle, which acts as kind of a time delay, then to the ventricle.

A concealed pathway is essentilly a short circuit. They find them by using electrodes and computer to map the heart. The electrodes measure the magnitude and exact time of the signals. The computer of course records this info along with the exact location of the electrode. Most locations have an expected time/magnitude signal. In my case, they found a signal on top of ventricle that had the exact same time/magnitude as a signal at the sinus node, which started the tachycardia. They made a burn on that one spot (on the ventricle), ta da, problem solved.

That was on an ablation performed at the Cleveland Clinic. At two other clinics they were trying to burn the signal at the sinus node or at least as close to it as they could get. I count my blessings that they stopped when they did.

I hope this helps, Bob

[WPWGuy]

regarding your question, the topic is real technical.  Looking at the procedure note written up by my EP, it appears that they were able to make some inference about the pathway by comparing certain conduction delays, during normal rythmn vs with bundle branch block.

[WPWGuy]

momto3 - if I may ask please, where did you have your successful ablation performed?

dquenzer - please tell me more about your experience at the Mayo (i.e who was your doctor, how did you get set up at the Mayo, how long did it take to get into see anyone, and how did you go about finding your doctor?)


jobob52 ford - its nice to hear of your experience with cleveland clinic.  I was wondering how long it took you to get scheduled and thru your procedure?  Also, if you dont mind, how did you find your doctor?


Thanks for sharing your experiences...

[Momto3]

Both of my ablations were done in Cleveland.  The first was for RVOT and the second was for LVOT. Prior to the first ablation, I was having a LOT of pvcs. The first procedure significantly reduced the frequency of the pvcs (Holter recorded about 6000 - which was GOOD for me). But, because the frequency was causing cardiomyopathy, the doctors were treating me somewhat more aggressively...Hence, the second (or "touch up") ablation about 4 months later.

Hope you are feeling better
connie

[jobob52 ford]

Dear WPW.
It would do you well to check out this site;
http://www.clevelandclinic.org/heartcenter/pub/guide/success/arrythmiastory.htm
When I scheduled my procedure there was a 4 month back-log.
My local Cardio forwarded my history to the Cleve. Clinic, which helped the Clinic determine if they felt they could help me or not. I arrived at the Clinic on Thursday for pre-op work, blood, EKG,etc. Had a 4 hr. procedure on Friday, walked out of Clinic on Saturday and flew home to Oregon on Sunday, back to work on Wednesday.   Piece a cake!
Wishing you the best of luck!  Bob

[Cashiers]

First time posting.  Had ablation 3 month ago for PSVT, re-entry and ablated 5 places, did stop that I think so far, however the pvs's and jumping around of rate are making my life miserable almsot every day.  An event monitor is on its way to me.  Hope it acts up for it.  The hardest part is the tightness and pressure in my chest to the point can't wear bra.  Had Cath done prior to EP/Ablation and clean as whistle.  Trying to understand things I need to ask, should a EP study be done before each ablation?  Sounds like it.  Need to have Ablation done again before end of year insurance. Doctor documented 4 foci of pvcs on 1st but he seems like hesitant about ablating the pvcs. Appreciate any opinions