Pulmonary Focus of Atrial Arrhythmia

[arthur]

I have recently undergone an ablation procedure for PAF.  A few foci (mostly in the left pulmonary vein ostia) were found to result in premature depolarizations; one was confirmed as leading to my PAF and was toasted.  The other foci were found responsible only for PACs.  I remain PAF-free (for 5 months) despite intensive exercise (which used to provide the adrenaline trigger leading to PAF).  

My current symptomology revolves around the remaining PACs which increase (up to 6/min for hours) several hours after exercise.  If I do not exercise (for more than a week), the PACs withdraw to near absence.  My cardiologist has me on flecanide and it suppresses PAC production about 50%.

In addition to the PACs, I also have an "internal tremor" which appears to be caused by one of these PV foci.  Apparently an involvement with something like my phrenic nerve system is amplifying the PV depolarizations and presenting itself as barely palpable nervous sensations as far up as my throat and as low as my abdominal muscles. Fortunately, this PV focus is relatively unproductive and yields few PACs, but is just as troublesome.

So, two questions:

(1) What is the likelihood that PACs of the sort described can be treated by ablative procedures? (I realize that PACs are generally deemed a nuisance and are not life-threatening, however, at some point, the sheer number and frequency must demand a interventional cure).

(2) Is the presence of an "internal tremor" suggesting the existence of a "specially" excited PV enough justification for an ablative procedure? ... or do we wait until things get worse (like a recurrence of PAF).


Thanks for your kind attention to these questions.

[Cleveland Clinic, MD]

Dear Arthur,
First, the great news is that you are afib free! Where did you get the procedure done?  Concerning the PACs, I think ablation is an option is medications fail to control them and they are symptomatic.  I think there is a high risk of one of them triggering more afib in the future so an additional ablation at some point would be something to discuss with your doctor.

[stevebu]

Arthur

Does your medication have a negative effect on your work outs?

I had RF ablation done 7 months ago for SVT.  It has cured this problem but i am still bothered by PAC's.  After work outs, for about 4 hours, they are about 30 per hour.  Then they seem to fade away.  Sometimes I wonder if the ablation might have contributed to them, but I had spells of them even before the ablation.  There must be something else contributing to them.  I will not take meds unless they become much more frequent.

Steve    

[arthur]

No negative effect on workouts (45-60 min jogging/sprints).
I have been on low doses of a beta-blocker (toprol) and the sodium-channel blocker (flecanide)...neither separate nor in combination did these drugs result in anything more than a little dyspnea after sprinting.  I was at minimal doses.  I believe higher doses of the beta-blocker could make it more difficult to recover during stressful exercise.

[arthur]

The ablation was conducted at the University of Pennsylvania Hospital under Dr. Francis Marchlinski.

[Lauro]

First off, I want to comment Arthur on his post.  I only wish, I could explain things as well as he does.

Arthur, what tests were performed to diagnose your conditon?

Thanks,  Mary

[jan]

Arthur, I am so glad you posted where you had your ablation and that is was the Univ. of Penn. I have told my husband if at any time I need any procedure, that is where I want to go.

[Lauro]

I wish there was a list that patients had access to, listing various heart procedures (and other non heart procedures,too)and the physicians who specialize in a particular procedure.

Saves time, money and most importantly, the well being of the patient.

Jan, had you heard of this doctor before this post?

I am close to the Texas Heart Institute and doing some checking here but will travel to the most experienced,when it comes to health care.

Best of Luck To All.

[arthur]

Tests.  I had undergone a battery of tests to (1) establish it was indeed AF I was precipitating with exercise and (2) that the source was not some unusual physical problem like tumors (pheochromocytomas), esophageal irritation (GERD), esophageal diverticuli (which can lean on the heart and result in arrhythmia), or arterial embolisms.  So I underwent CT scans, chest sonograms, blood tests, Holter monitor, other ambulatory monitors, stress tests (with echo and with radiotracers to detect possible ischemia).  In the end, all the really bad stuff noted above was ruled out, which left us with adrenaline-induced PACs leading to PAF.  Fortunately, during the past several years major breakthroughs have revealed that many atrial arrythmias are due to overactive pulmonary veins (actually the cardiac tissue sitting on the inside walls of these veins where they are attached to the atria of the heart).  Prior to these findings RF ablation had already begun to be used and much data has accumulated to allow experienced EPs to conduct such ablations relatively safely.  I was also fortunate to have a cardiologist at the time that recognized his limitations and was smart enough to recommend that I go see Marchlinski (U of Penn).

[Lauro]

Thank You, Arthur.

I also had the pheochomocytoma test via the Endocrinologist. I had the CT Chest scan beacuse of 'funny sounds' in the chest, via the Pulmonary Doc. He also did the Spiromety test of which this was not quite up to par.  He also did a Broncoscopy.
I had an Echocardiogram with a cardiologist of which he never gave me the results. (figured this was ok since I never heard)

I had an EGD and Andominal Ultrasound via a Gastro Doctor. EGD showed GERD.
All these physicains were to consult one another.  None of them have. So, it is up to me (the Novice) to try and figure where I go from here.  I believe it is harder for a female to accomplish this, at least in my case.

On the CT chest scan it did show that the left adrneal gland was
enlarged but no mass was seen.  Pulmonary Doc made no comment on this finding.

Thank God for your wonderful doctor that Ego did not get in his way of recognizing his limitations and referred you to a Specialist.  

Thank You Arthur, and Good Luck To You.

[Francine Taylor]

I also had a successful ablation done at Univ of Penn. by Dr. Marchlinski in Sept 2000. After two unsuccessful ablation attempts at curing Atrial Flutter at Cooper Hospital in Camdem NJ I was sent to Univ of Penn. I still get SVE's, lots of them. Most recent holter reading showed 5000 in 24 hours. I'm on flecainide , so hopefully this will treat them.

[arthur]

Coordinating physicians.  A medical problem that doesn't seem to fit directly within a specialist's area of expertise can be a challenge to solve.  I had gone to three cardiologists, an endocrinologist, an ent specialist, and a cardiothoracic surgeon before being referred to the EP.  All the while it was up to me to figure out the next step, and that wasn't always the right step.  I had read extensively about every concievable ailment that could explain the symptoms, and often found that many of the specialists I consulted with had very little understanding of basic anatomy surrounding the heart (this was a shock; the exception was the surgeon, thank goodness).

So, the bottom line, is that you definitely need to talk to a lot of doctors and people with similar experiences, and hope that the hypotheses you develop will eventually lead to a solution.  It's amazing that this is the state of the medical art, but it is what it is.

[jan]

No, I haven't heard of the dr., but U of P is a 5 star hospital in cardiology according to HealthGrades.com and I live in NJ. I have heard others give glowing reports, too.
You can check out their site, www.healthgrades.com for hospitals according to the procedures, and dr.s, but when it comes to the dr.s ...  There is a section called "your opinion" and when someone submits one then an icon for survey results will come up that others can check it out. I have filled out this survey for a handful of dr.s all good, but one. Guess what. The one that was somewhat didn't show up, even after doing at two different times.

[Lauro]

Thanks again, Arthur,  Forgive my ignorance, but what does EP stand for?  

I thought it was only FEMALES that got the run around but it looks like you went thru the same things I am now.  I am getting preety sick of this.  
I too am on the Internet checking symtoms. Gads, I can come up with so many but it is localized to the chest area.

Today, I called the office of another Gastro Doc that was referred.  The gal who answered the phone said "Yeah"...
I went on to say, "what does Yeah mean" and only then did she identify the gastrolenterologits group she works for.  I asked questions about this doctor and in an annoying manner, all she could say was he treats the stomach. She had no idea if he specialized in Motility Disorders (which I am being checked for).

I told her she was  unprofessional and she said, "are you thru with me".  I said yes, and she said "good bye"...<grin>

So, it is not only some doctors but their Medical staff too.  

My hubby said "good help is hard to come by" as medical office staff is one of the lowest paid.

Sorry, I had to vent.  It is sooooooooo frustrating to the patient to do all the leg work and keep stumbling on pebbles on the road.  

I am in a large city in Texas and had hoped to find someone here before searching elsewhere.

Jan, thanks for posting the www. site.  I will go there now.

Mary

[arthur]

EP - an Electrophysiologist - a cardiologist specializing in the heart's wiring system.  These are the guys who will use catheters and wires to figure out what internal electrical disorder is causing an arrhythmia...and perform an RF (radiofrequency) ablation to burn out the troublesome spot if one is found.

[jan]

A large part of the reason I am leaving my cardio. is because of his staff.  You would not believe the offenses and I am not talking about social graces, either. I won't even call him with a problem anymore. I will just wait until I can make the change, which unfortunately will be in June for my 6 month check up.

[Lauro]

I think doctor's actions and unprofessionalism come when they do not like a patient or when they are stumped and do not want to show their ignornace. This is my personal opinion.

[Lauro]

Well, I got up enough nerve to call this large cardiology group today and left 2 messages with no return call.  I then called a an hour ago and told the receptionist that i will hold for a nurse and did not care if I held all week-end.

Finally, a nurse came on and I finally got the results of my Echocardiogram that I had 5 months earlier. I also asked why the doctor never returned our calls about tests results and meds he had given me 5 months earlier. She had no answer.  She was very nice and assured me that so far all tests were ok and that I do need a stress test as she saw it was never done.  I told her it was not done because the doc never scheduled it.  So, she assured me that HE would call me as he  comes in on week-ends to view his messages.   I want to discuss Arthur's post and all the other tests I have had since I last saw  him, 5 months ago.

I hated to have to put my foot down today but the more one worries for none compliance,the worse we all become and we all are entitled to a Correct Diagnosis, Good Treatment, Peace of Mind and on the right road to Better Health.

Wishing you all a very nice week-end.

[BUTCH 442]

WELL FOLKS IM A 49 YEAR OLD MALE I WENT TO THE E.R. WITH THUMPS IN MY CHEST THEY PUT ME ON ALL TYPES OF MEDS  NOTHING WORKED  SO AFTER 3 YEARS OF THIS  THEY SAID LETS DO A  ABLATION SO THEY DID  THEY TORE A HOLE IN MY HEART WITH THE WIRE SO THEY STOPPED THAT  AND I WOKE UP WITH A CHEST TUBE IN ME  SO ONE WEEK STAY TO RECOVER FROM THAT NOW THEY SAY  WE WILL PUT A PACE MACKER IN SO THEY DID ITS SET TO FIRE 80 BEATS PER MIN  I WAS 55 PER MIN BEFOR THE PACER  WELL I STILL GO INTO A FIB  ALOT BUT THE PACER WILL NOT LET IT STAY  FOR A LONG TIME SO IT HELPS  IN THAT RESPECT THESE ARE THE DRUGS IM ON I STARTED OUT WITH A DRUG CALLED AMOROADEN I TOOK THAT FOR 3 YEARS IT ALMOST KILLED MY THYROID AND IT CAUSED MORE A FIB SO MEDS CHANGED TO  SOTALOL 480MG 2 TIMES A DAY  VERAPAMIL 250 MG PER DAY NORVASE 5 MG PER DAY LIPITOR 10 MG PER DAY COUMADIN 6 MG PER DAY TAPAZOLE 30 MG PER DAY AND IM STILL IN A FIB NOW THEY WANT TO DO THE OPEN HEART SURG. CALLED THE MAZE IM TO WEAK TO DO IT RIGHT NOW I JUST GOT OUT  OF THE HOSPTIAL I WAS IN FOR 2 WEEKS IF ANYONE OUT THERE HAS ANY COMMENTS PLEASE  FORWARD  A E MAIL TO ME IN CASE I CANT FIND THIS SPOT AGAIN WWW.***@**** I LIVE IN MASS. AND THE WORK HAS BEEN DONE A U MASS HOSPTIAL IN WORCESTER IM AT THE END OF MY ROPE HEAR  PLEASE HELP