Ablation for accessory pathway?

[momtotwinsplus1]

Hi and thank you in advance for you time. I am a 39 y/o female who has been diagnosed with an accessory pathway. I believe I have had this for 12 years, since I remember my first EKG showing inverted p-waves, even though they told me the tech had probably put the leads on wrong. Subsequent testing (EKG,ECG, 48 hr holter all normal except for pathway) has revealed that I do indeed have an accessory pathway located in the upper right area of my heart (thats how they explained it to me), I assume that means only one foci?
My symptoms are pacs/pvcs 1 out of every third beat (beat, beat, pause beatbeatbeat), 2 years ago while under serious stress I had a couple of episodes of NSSVT, lasting only 30 seconds or so. Since then just the annoying constant pacs/pvcs.  Occasionally, I get what I assume are several missed/extra beats in a row, it feels like my heart is flopping around like a fish. VERY DISCONCERTING! I am on 30mg Propranolol, 10mg HCTZ (for blood pressure)
So my questions are how did I get this? I was recently diagnosed with obstructive sleep apnea could that be a cause? Are these episodes of multiple missed/extra beats in a row a concern? And would you consider me a candidate for ablation? It seems with only one foci (assuming its only one) it would be an easy fix. Would it cure me of all pvcs/pacs or am I likely to develop another accessory? Also, is a juntional rythym caused by an accessory pathway.
Thank you so much for your input!

[Michael J. McWilliams, M.D.]

So my questions are how did I get this?

I am not sure what you mean by "this."  If you mean the accessory pathway (AP), you were born with it.  If you mean the PAC/PVCs, there is not good answer.  Some people get them and others do not, some people notice them and others do not.

I was recently diagnosed with obstructive sleep apnea could that be a cause?

OSA can increase your body's adrenaline levels.  Some people have more PAC/PVCs when they are stress, drink caffeine/tea, sleep deprivation, etc.  If you used a CPAP machine and your PACs/PVCs decreased, that would help answer your question.


Are these episodes of multiple missed/extra beats in a row a concern?

I would want to see what your heart is doing on a monitor while you are having the symptoms -- either with a Holter, event monitor, or home telemetry.  If they are simple pac/pvc's they are not a concern.  With the AP I would want to make sure it isn't atrial fibrillation or short runs of SVT that can be fixed with ablation.

And would you consider me a candidate for ablation?

It depends on what the monitor showed and where the pathway is.  If you have an accessory pathway with no SVT, I would not ablate it.  It is reasonable to do an EP study to try and induce SVT and also check the refractory period of the accessory pathway. If the pathway has a long refractory period and you do not have SVT, I would not ablate it.  It also depends on where it is -- if it is close to the AV node and you are minimally symptomatic, the risk of needing a pacemaker may be greater than the benefit of ablating the pathway.

It seems with only one foci (assuming its only one) it would be an easy fix.

You never know how many pathways there are until you do the EP study.

Would it cure me of all pvcs/pacs or am I likely to develop another accessory?

AP are there from birth.  If they ablate one and there are none left, the will not grow back.  There is always a low risk that the accessory pathway will recovery after ablation, but this is less than 5%.

Also, is a juntional rythym caused by an accessory pathway.

I have never read that AP are related to junctional rhythm.

It might be worth seeing an electrophysiologist for a second opinion.  We sometimes shy away from using beta blockers (propranolol) when accessory pathways are present.  This may cause problems if you develop atrial fibrillation.

If you want, let me know what major city you are near and I will try to recommend an electrophysiologist if I know someone near you.

I hope this helps.  Thanks for posting.

[tickertock]

When speaking of shying away from using beta blockers when accessory pathways are present in case of a-fib, are you referring to accessory pathways like WPW, because one doctor suspected  I might have an concealed accessopry pathway and I take 100mg of atenolol daily, no tachycardia whatsoever while on it or as i asked in another comment yesterday Is a-fib less dangerous in CAP than as in true WPW because they only conduct retrograde therefore beta blockers are safe to use in this case. Just wondering I'm a little confused.

[PikaPika88]

I also wondering how long it takes or how quick it could be for the recovery of the AP after ablation?  Mine one was able to induce SVT on the next day after the HIS bundle ablation.  It is the anterograde one.  I don't know it was normal or not?  It makes sense to me.  When my ventricle didn't receive signal from the Atrial then it grows a pathway to send signal.  Isn't it that is what we want our body to react?

I don't agree and don't believe that the AP is borned with it.

[tickertock]

Just realised it was $20.00 to post a question on the heart rhythm forum when i clicked on post a question, when I first posted it was free, It's well worth the price I have no complaints about that and the service is invaluable, I just want to add I wasn't trying to get an answer for free, I'll pay another day for my question.

[Michael J. McWilliams, M.D.]

TT: It should be different for concealed AP.  The danger is conduction from the atrium to ventricle, concealed APs only conduct retrograde from ventricle to atrium.

PP88 People are born with AP.  The do not grow later in life.  there is a chance that it wasn't manifest until the AV node was removed.  I am not sure that what you are describing makes sense though.  In order to have ante grade tachycardia  you would have to have two AP to produce an SVT from above -- something doesn't make sense to me from you described.

[tickertock]

What can I say but on behalf pika and myself , many many thanks, this is exactly what I thought regarding accessory pathways maybe that's why the beta works wonders for me, it has never manifested itself on any of my EKG only suspected and by an internist whom I've known for 30 years and I've seen numerous cardios and one EP who never mentioned such a thing, only thing the EP stated was that my heart normal and to go on living and forget I had heart , which I've tried to do but it is so hard when you are so heart aware even when the beats are normal! Thanks once again for your thoughtfulness and your BIG heart. May God richly bless you.

[momtotwinsplus1]

Thank you for your speedy reply. Re: the multiple beats..when I tested using a holter they told me I was having multiple pacs sometimes 2 or 3 in a row, and mostly at night. I always assumed that the accessory pathway was causing the pacs/pvcs. .. Also, I guess Im not really sure what a junctional rythym is, I thought it too was related to the pathway. I live in Portland, Oregon...I would like a recommendation if you have one.
Thank you again for your time!

[kellebelle4]

Hello,

Greetings from Washougal, Wa.  Momtwinsplus one. We have a great resource of ep's in our area. I just had an ep study in at the heart and vasuclar center here in Vancouver, wa. After a trip to the er a month ago I was finally referred to the an ep he has been very helpful. So I would ask your cardio doctor or general doc to refer you to someone in our area. Feel free to email me at lundk444atcomcast.net and I could list a couple for you.

TT........... glad to hear you don't get the tachachardyia........it can be so unsettling. My ep study was informative they thought they would find something to ablate but after 2 plus hours in the cath lab they decided to not push it. My ep said I have an exteremely sensitve sinus node that reacts quickly to any stimulus. So we are going to continue to treat it with beta blockers.......I was relived and disappointed at the same time. I have been waking up at night with tach for some time now and just wanted a conclusive answer. Anyway the ep study was very interesting, I slept through most of it I am still  sore from the incisons but am enjoying the rest....Anyway just wanted to say hi...........good to see you on the forum. Kelly

[ireneo]

Hi, I live in Portland too. My all time favorite cardiologist/EP is Dr. McAnulty. He was at OHSU when I saw him. Recently he's moved down the hill to Good Sam. However, OHSU, being a teaching hospital(s) would still be an excellent place to go even without Dr. Mac. (I admit - he's my favorite)

[tickertock]

Well its good to know nothing serious was found in your Ep study, you probably just have a hypersensitive sinus node, sort of the diagnosis I got from doctors and cardios since only sinus tachycardia was ever noted beside PVCs. From my understanding the sinus node is something most EPs stay clear of ablating or modifying as the results are usually short lived and the complications outweigh the benefits with the procedure, I'm lucky that beta blockers works perfect for me in the regards, in the maintime be well and I'll drop you an email soon.

[PikaPika88]

Thanks Dr. MJM and Tickertock.  Now it charges for a posting question so would it still apply to 2 questions a year or six month?

Like our body every minute it can grow, either wanted or wanted grows.  You may be using the word "manifest".  Sound like all our body is having a time bomb!  Some people can grow a new vessel when one is blocked.  Some just unable then end up with muscle died without the blood supply.  I suppose the pathway can grow too if your heart with insufficent signal to commuicate to each chamber.  I know that everyone is disagreed.  If I born with it then my cardio should know the total of how many pathway that I have in active and in-active?  Some of these links might be interested to you and others.

http://www.blackwell-synergy.com/doi/abs/10.1111/j.1540-8159.1992.tb06493.x?cookieSet=1&journalCode=pace

http://eurheartj.oxfordjournals.org/cgi/content/abstract/7/5/444

I wish I would have a cardio like you.  If one day I can afford to fly over there then I'll bring all my medical history to see you.  I know you can explain it to me.  

Thanks again.