ablation of vagal reflexes

[tallron]

I am a 60yr male without any known structural heart problems.  I have had worsening atrial fibrillation for 15yrs in spite of giving up caffeine and alcohol and taking 6 medications at one time or another.  My condition is partly inherited and partly due to my life long dedication to exercise (5 marathons).  I have always noted a vagal component to my AF, but this became much stronger about 2 yr ago, when simply eating or sleeping could trigger an episode.  I have had 2 PV isolation-type ablations now – one ostial, one atrial, but still have AF lasting 1-3 hr about once per week, even though I take Amiodarone and Toprol, daily. Also, at my request, I have taken Enalapril and Diovan for 3 yr.  I am considering a third procedure and am interested in the vagal reflex ablation of Dr. Pappone.  The research behind it seems compelling and the clinical claims are remarkable, but I understand that there is some question about its validity.  What is the current opinion of this procedure at your clinic?  Thanks.

[CCF-M.D.-MJM]

Boy that is a tough question.  I asked a few electrophysiologists what they thought.  It may be too early to tell.  The procedure is still experimental and the data is still very early. I agree it is encouraging, but I think it is way too early to tell. We do a lot threepeat ablations here and have fairly good success.  You are always welcome to see one of our electrophsiologistst to see what they think and have to offer.

I can't offer much more than this for now.  Hopefully your next procedure, if you decide to do another, will be successful.  Good luck.

[Erik36]

Great question! I will be awaiting the doctor's response. I think I have Vagally mediated A-Fib also.

Erik

[pon 68]

I AM A 54 YR OLD MALE WITH WHAT I THINK ARE VAGAL RELATED HEART PROBLEMS. HAD A HEART ATTACK 9 YEARS AGO THAT HAS NOT CAUSE ANY PROBLEMS UNTIL ABOUT 8 MONTHS AGO. I ALL OF A SUDDEN STARTED HAVING PULSE PROBLEMS THAT CAUSED A VISIT TO ER. SINCE THEN I HAVE HAD ALL THE TESTS INCLUDING MONITORS AND ANGIOGRAM. I HAVE A EP SDUDY SCHEDULED THIS WEEK THAT HAS ME SCARED BECAUSE THEY WANT TO INSTALL A DEFIBRILATOR. I KNOW I HAVE LEFT OUT MANY DETAILS BUT I AM CONVINCED THAT ALL THESE PROBLEMS WERE CAUSED BY MY VAGAL NERVE BEING DAMAGED WHILE WORKING ON A CAR. I KNOW I HAVE OTHER HEART PROBLEMS BUT NOT TO THE EXTENT OF HAVING A IMPLANT. ALL THESE PULSE ISSUES WERE VERY TROUBLSOME FOR 7 MONTHS BUT SLOWLY STARTED TO DIMINISH IN TIME AND 3 WKS AGO IT WAS LIKE SOMEONE TURNED ON A SWITCH AND ALL MY ISSUES STOPPED. GOOD PULSE,GOOD EVERYTHING. CAN THIS NERVE CAUSE THIS MUCH TROUBLE? MY DOCTORS DONT WHAT TO HEAR IT. IF THIS NERVE IS STRESSED SEVERLY CAN IT ALSO CAUSE THE HEART TO BE WEAKENED ENOUGH TO CAUSE LOW EF. I KNOW I LEFT OUT A LOT OF DETAILS BUT AFTER LOOSING A SMALL AMOUNT OF WEIGHT AND WATCHING MY DIET THINGS HAVE RETURNED TO WHAT I CALL NORMAL.

[dquenzer]

What kind of PV ablation did you have?  As I understand there are two types.

I had a PV ablation one year ago and is working fine.  The type I had was a large circle that encompassed both pulmonary veins, and not just the type that went specifically around each of the pulmonary veins.

I'm not sure if one procedure has more success than another, but it might be worth asking.

[tallron]

dquenzer,
it sounds like you had an atrial ablation, which i had about a yr ago. earlier i had an ostial ablation, which only involves the opening of the pv.  the first kind is supposed to be about 20% more effective.  though in my case, the ostial, done first, helped me alot and a follow up atrial ablation has not helped at all.  having had 2 pv isolations and still af about once a week, i think my case is more involved, hence, my interest in the vagal ablation.

[StephPT]

I am very interested to hear about this vagal ablation technique.  As mentioned in a previous post, I have swallowing induced SVT, and I'm pretty sure it is vagal in origin.  I have an appt. coming up with an EP at Thomas Jefferson that specializes in the autonomic nervous system.  So nice to know I'm not alone.

[uptowngirl]

What is vagally mediated A-fib?? How does it differ from regualar A-fib?

Thanks.
Uptowngirl

[vmpaf]

I have not heard about Pappone's ablation of the vagal reflex, but will read up on it.  Regardless, there was some work done on this a long time ago on dog hearts (istr) - check PubMed.  Such work is not of course entirely parallel with human hearts or with pre-existing vagal AF, since generally they have to elicit the "abnormal" responses from the otherwise normal heart.  However, what I do remember was that the result was not as expected, indicating that the vagal response, indeed the whole autonomic relationship with AF, is not at all simple.

The paper which Prof Camm of St George's Hospital Medical School in London wrote in Falk and Podrid supports the idea that whilst vagal AF can be a useful classification, it is by no means a simple affair.

Finally, I have had an ablation at one of the world's leading AF/ablation clinics.  I brought the subject of my own generally vagal response up with the EP, and he responded that "80% of the patients they see have vagal responses".  The worst of my own vagal responses disappeared overnight with the ablation, though I still have a residual tendency towards vagal symptoms when the odd breakthrough arrhythmia threatens.  I also have ventricular premature contractions (PVCs) which occur along with vagal symptoms - they are worst when my heart rate is low, and after certain foods.  It appears that this is not unusual for these benign ectopics.

On balance, I would say that it is the AF that should be treated along tried and tested lines (PV ablation, flutter line in the R atrium, and mitral isthmus line in the L atrium) along with any obvious extra-PV foci, before entering upon territory that may be less proven.

Vicky
http://www.vagalafibinfo.fsnet.co.uk/

[vmpaf]

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14707026,12521345

I read these as:

- if the EP tests for withdrawal of vagal response after left atrial work (PVs), this helps to define an end-point.  It's therefore not the main aim of the procedure, but helps them to know when the procedure is complete

- ablating the right atrium for vagal denervation makes it worse (this was the method tried in the dog heart, ISTR)

[Erik36]

It is A-Fib brought on by Vagal tone usually controlled by the Vagus nerve. I'm not sure of the exact mechanism involved. You know how some people get A-Fib from exercise, alcohol or caffeine or emotional distress? I get A-Fib from moving a certain way, jumping on to my bed, cold fluids or burping. Burping can also terminate my A-fib. All of these things stimulate the Vagal nerve. They also say that someone with Vagal A-Fib can get worse from beta blockers, but I've been on beta blockers for years and it hasn't affected me.


ERIK

[jdgb60a]

I have gone into a.fib 3 times in the last 7 months all during the night when my stomach is bloated , lots of gas from eating something that disagrees with me or eating late a night. Could this be the vagus nerve related issue? My cardiologists think I'm nuts when I bring up the gas and bloating.My digestion is somewhat compromised because I have had colon operations that have left me without the valve that separates the intestines.

[tickertock]

Do a google search on Dumping Syndrome, you might find it very interesting to read.Don't read just one article , read several on it.