Return of AVNRT after 2nd RF ablation

[heartofgld]

37yrF hx of SVTx7yrs. Controlled well with Diltizam until Sept 06' at which time I presented to ER in AFib w/rapid vent response. IV meds unable to convert and nedded DC cardioversion. Had EP study/flutterline abaltion and failed attempt to ablate SVT(AVNRT). Had 2nd ablation in Nov 06' where 9 burns were made to destroy fast pathway. Post procedure appt ekg revealed accelerated junctional escape. Was given event monitor again. Tracings revealed a host of different atrial tach arrhythmias. On Dec 22 after having a syncopal episode, tracing was sent and showed return of SVT, atrial flutter with rate of 300+. EP has now referred me to a specialist at the Brigham&Woman's Hosp in Boston,MA. for consult to undergo a cryoablation. He said that my last RF was too close to the AV node and further burns in that area would surely damge the node requiring me to need a pacemaker.
My questions are:
1. My RF ablations have always been on the right side. Could my problem be left sided, requiring a transeptal approach?
2. How rare is it that someone would require more than 2 abaltion procedures to wipe out SVT?
3. How successful are cryoablations for SVT
4. What are the statistics that a pacemaker is needed after a cryoabaltion procedure when 2 RF abaltions failed to work?
5. What are the chances of heart muscle damage after months of continued tachycardia (resting HR usually not below 100 with high atrial rates sometimes exceeding 450?

I am not an anxious person but the continued failure is starting to wear on me. Thanks for any input you can offer

[CCF-M.D.-MJM]

Hello,

Very good questions, but difficult to answer without seeing the electrograms.  The fact that you mention a fast pathway ablation makes it even more complex because fast pathway ablations are very rarely done these.

1. My RF ablations have always been on the right side. Could my problem be left sided, requiring a transeptal approach?

You mention atrial rates of 450 beats per minute and ventricular rates of 100 beats per minute.  This sounds like an atrial tachycardia, but a full EP study is needed to truly answer this question.  If this is an atrial tachycardia, it could be any where (right, left, or septum).  Your EP doctor could be concerned because the origin is so close to the AV node that he would certainly cause AV block if they ablated there - I very recently was involved in a case with this same concern.  If is left sided, transeptal approach is a likely approach.

2. How rare is it that someone would require more than 2 ablation procedures to wipe out SVT?

It is fairly common for lesions near the AV node.  You would rather redo the procedure than risk complete heart block.

3. How successful are cryoablations for SVT

Slightly less successful than RF ablations but with less risk of complete heart block.

4. What are the statistics that a pacemaker is needed after a cryoabaltion procedure when 2 RF abaltions failed to work?

I think there are only a few cases of complete heart block with cryoablation.  If they use cryo, your risk of complete heart block is very low.

5. What are the chances of heart muscle damage after months of continued tachycardia (resting HR usually not below 100 with high atrial rates sometimes exceeding 450?

The longer your atrium is at rates that high, the more likely you are to have damage.  Early on in these situations, the damage (remodeling) is almost always reversible.  Ventricular rates in the low 100 hundreds are unlikely to cause significant problems besides increased fatigue.

B&W is a great hospital and should be able to answer you questions and help.  Good luck and thanks for posting.

[emilycaitlin]

Hi there heartofgold,
I had been wondering how you were doing, after reading your post about the junctional escape rhythm. Just wanted to wish you all the best with the cryoablation, if you do choose to have it done. I'm considering a "regular" ablation now for my svt, as my cardio has recommended it. Hope the dr's at Brigham Young are able to get things sorted out for you, it must be so terribly frustrating for you now. I have not had rhythms nearly as bad as yours, but even on the toprol xl my hr has also not fallen below 100 since this past summer, and I wonder about the effects of that and all. Best wishes for you and please keep us posted on your progress, em.

[heartofgld]

Thanks for the well wishes...I'm gonna need them! I was hoping to start the new year in picture health but I am no closer now than when this whole thing started. I just wish there was some magic wand that they could wave over me, but I guess that's only in the movies. I just try and take one hour at a time, never mind one day. I'll keep you posted. Hope you have success with your ablation:)

[iAmEllen]

How come cryoablation isn't common these days even though the risk of complete heart block is lower?

[bama jane]

good luck to you I had a failed ablation some years ago and I know how tough it is after you have gone through that and it doesn't work. I don't think it is easy for someone to understand how this makes you feel unless they have been through living with an arrhythmia.  It is like living with a lion in the basement.  You never know when it will show up and cause a trip to the hospital. I hope they can help you and find a way to give you a better quality of life. Maybe the third time will be your charm.  I sure hope so.

[heartofgld]

Thanks again for your posts. I am meeting the new Dr tomorrow at Brigham&Woman's Hosp. will let you know how it goes. I'm hoping for some good news:)