Ablation & Permanent Pacemaker

[sueinns]

A friend of mine is undergoing ablation for atrial fibrillation.  He told me that part of this procedure involved implantation of a permanent pacemaker, which surprised me - first time I ever heard of that.  He was given a booklet that stated the follwing
NEED FOR A PERMANENT CARDIAC PACEMAKER
After a successful AV node ablation the ventricles will no longer respond to the electrical signals from the atria. In other words, although the atria may continue to fibrillate at up to 800 beats per minute, the ventricles will be "doing their own thing". In almost all individuals after ablation the ventricular rate will be about 40 beats per minute (and very regular). This 40 beats per minute may seem slow, but it is sufficient to maintain your blood pressure and sense of well being at rest. Unfortunately, even with exertion, the ventricular heart rate will not rise much higher than 40 beats per minute. You would not feel very energetic if we allowed your heart to stay at this slow rate. In order to allow your ventricular rate to rise appropriately with exercise a rate responsive pacemaker will be necessary. These pacemakers are very sophisticated (and remarkably small these days). It is possible to easily program them (like tiny computers) to keep your heart rate relatively slow with inactivity (for example 60-70 beats per minute) yet increase the paced heart rate gradually to appropriate higher levels as the sensor in the pacemaker detects increased activity.
The pacemaker is usually implanted prior to the AV node ablation procedure. The implant is done under local anaesthetic, just under the skin below the collarbone.

Had anyone here ever heard of this or had it done?  I'm considering ablation for SVT but would definitely not want a permanent pacemaker.

[SillyHeart]

Ablation for a-fib is not the same as ablation for SVT.  A patient with SVT does not need a pacemaker implanted except in the rare instances that the AV node is accidentally ablated.

[va_tony]

Yes, this is one of the standard options for dealing with afib. It's appropriate for those who are highly symptomatic (unable to live their life normally because of chronic afib.. their heart races & they feel weak and dizzy) and have serious side-effects from rate or rhythm control meds and are otherwise poor candidates other types of ablation (e.g., pulmonary vein isolation).  Usually, the patient also has other heart problems and a pacemaker might be indicated anyway.  I have afib myself that's somewhat controlled by meds. But since I'm asymptomatic (absent serious symptoms) and have several med options, I would never consider such a drastic solution.

Has your friend talked to a good electrophysiologist (cardiologist specializing in arrhythmias) and ruled out alternative treatments? One shouldn't rush into this decision lightly. I'd even advise getting a second opinion.

[va_tony]

Expanding on my last answer, here are the usual ways of dealing with chronic/persistent afib:

1. rate control ---- a beta (or calcium channel) blocker is prescribed to lower heart rate while in afib as well as an anticoagulant to prevent stroke (usually coumadin or aspirin).  The patient lives the rest of their life with afib. Usually this is reserved for those who show very few symptoms.  A large study (AFFIRM) a few years ago actually show that this method resulted in the lowest mortality and morbidity rates.

2.rhythm control --- a strong antiarrhythmic drug (e.g., amiodarone, sotolol, flecainide, rhythmol, etc.) is prescribed to maintain the patient in normal sinus rhythm. An anti-coagulant is also given. Occasionally, electrocardioversion is needed. At times (rarely), a pacemaker may be needed if the antiarrhythmic med used lowers the heart rate well below 60 bpm (bradycarida) giving symptoms of weakness and dizziness.

3. RF Ablation - usually the pulmonary veins are isolated resulting in a cure.

4. RF Ablation of the AV node and implantation of a pacemaker to pace the ventricles.  The atria are left to fibrillate but the patient doesn't feel any of the afib symptoms. Coumadin is also prescribed to avoid clotting and stroke.

5. Implantation of a pacemaker designed to pace the atria out of afib -- not very effective.  Sometimes used if the patient needs a pacemaker for other reasons.

6. Maze or mini-maze surgery. Surgery to electrically isolate parts of the atrium and so prevent afib. Maze involves open chest.  Sometimes used in conjunction with valve surgery.

If a patient has only PAF (infrequent or occasional afib), the options vary from doing nothing to the first two options above.