Ablation of RVOT PVCs

Hi!  I'm a 28 yr old mom of 1.  Back in June 2008, I was diagnosed with Neurocardiogenic Syncope (Vasovagal Syncope), Orthostatic Hypotension, and Sinus Tachycardia after passing out in under 4 min with a BP of 70/0 on a Tilt Table Test and a 24 hr Holter Monitor revealing 3,558 PVCs (Echocardiogram was normal).  I was put on a host of medications from Midodrine, Droxidopa, Flornef, Diltizam, and Metaprolol before getting pregnant at the end of 2009.  

Fast forward to 2012 and I'm in a new cardiologist's office.  New TTT, I survived until the 5 min mark with 48/36, a very small leak on a new Echocardiogram, and now 34,664 PVCs on the new 24 hr Holter Monitor.  Also revealed on the Echo and Holter, my heart rate likes to hang out in the upper 30s to low 40s on average.  My PVCs have become bad enough that I'm a walking microphone.  Heavy bass music alters my heart beat to beat along with the bass.  So does deep rumbling diesel engines, low flying helicopters, anything that causes deep vibrations, and coughing.  It's very painful, like someone taking a rubber mallet to my chest with each beat.  There are times where my entire chest will jump with the really painful PVCs.  I spend at least one day a week glued to the couch or bed because the PVCs are so painful, I can't move.  I can't take beta blockers, they give me the worst migraines of my life and make me really sick.  So after tearfully begging my cardiologist to make the pain go away, he refers me to an EP who takes a look at my Holter Monitor results and tells me I have RVOT PVCs and he wants to do an ablation ASAP.  I'm scheduled for one in just under a week.

I understand what they are doing with the catheter and such and going to burn the part of my heart that is causing the PVCs so I hopefully won't be in so much pain anymore.  But I have a relative that is worrying me.  She says she was told by her cardiologist that PVCs are a fast heart rate and the ablation is meant to slow the PVCs down and therefore slow the heart rate down.  And with my already low heart rate, it's setting me up to possibly never wake up one day.  I don't think she's right but I can't get in to ask these questions before the procedure and I'd like to be able to sleep without panicking.  I have a 2 1/2 year old and my husband is in the Military, I don't need this fear, too.

Could someone please explain this to me without all the medical jargon?  Please?  Also, what can I expect in terms of recovery?  My husband will be home for 6 days and then I'm on my own with our daughter.  Closest relatives are 2,300 miles away and we're too new to this station to be able to ask for much help from anyone.  Thank you in advance!!  ~ K

[is_something_wrong]

Hello.

Sorry to hear about your problems.

First, PVCs are not related to a rapid heart rate. Ablations are done to treat rapid heart rhythms, but that's a completely different type of ablation. In your case, ablation is used to treat the spot which is sending out lots of unnecessary impulses at random times, causing an irregular heart rate with "skipped" beats (PVCs).

I've never heard about noises affecting heart rhythm (bass, diesel engines and helicopters). Could it be imagination or does your heart (objectively) sync with a diesel engine? The reason why it sounds weird is that diesel engines rarely run slower than 500-600 rpm and if your heart did beat at 500-600 bpm you would be dead (no one can have a heart rhythm that rapid). Heavy bass usually runs at 120-140 bpm (I unsuccessfully tried to be a DJ when I was younger :) so in theory your heart rate could be this rapid, but I'm not familiar with one electrophysiological reason why the heart could be affected by music. If it was, it would not have anything to do with PVCs, it would sound more like sinus tachycardia.

Anyway, your normal heart rate would likely be unaffected by an ablation. When your heart rate is running in the 30s you may have runs of bigeminy; every normal beat is followed by a PVC, which means your heart rate in fact is doubled, but you can only feel half the beats.

I don't know if your orthostatic intolerance have anything to do with your PVCs. Regardless, 35.000 PVCs a day is quite a lot and if you got rid of them, I think your life quality would improve dramatically.

[itdood]

Your relative is very misinformed.  

Any cell in the heart can initiate the heart beat.  It just so happens that a group of cells in the atrium have the fastest internal clocks to "twitch" and that's what regulates the heart rate.  These cells are called the sinoatrial node or SA node.   The SA node naturally beats at about 100 BPM.  What slows it down?  The central nervous system slows it down.   The fact that other cells in your heart can, and will, twitch on their own to fire a contraction (heart beat) is terrific because it acts as a backup in case the SA node fails to fire.  The rest of the cells have a much slower internal clock though.  They usually fire around 30-40 BPM.    The SA node is the leader and it makes the various chambers of the heart beat in a synchronized way.

Sometimes these other areas of the heart fire faster than they should and this causes something called an ectopic or premature beat.  It causes the chambers to contract out of order and you can feel this.  When this happens it's called "enhanced automaticity", which just means they are more twitchy than usual.  However I'm guessing your PVCs are not the result of enhanced automaticty

Reading your top paragraph it looks like you've got Dysautonomia which is a central nervous system disorder.  It's probably causing your bradycardia (slow heart rate).  This over zealous nerve stimulation heading into you heart is probably also causing the PVCs.  maybe.  

If the root cause of your issue Dysautonomia, ablating (destroying) the RVOT cells that are firing PVCs won't treat the root cause.  However I don't know of any cures or effective treatments for Dysautonomia so it might be the only option.  Though I recall recently that some docs are resorting to cutting the nerve bundle that heads into the heart in severe cases of dysautonomia.  The heart will then revert to it's own internal pacing which is about 100 BPM.  If your dysautonomia is that severe perhaps you should research this option.

The RVOT is the most common source for PVCs and has the highest success rate for ablation of benign PVCs.  I think it's around 80% effective the first 6 months if I remember right.  However if the root cause is the dysautonomia, who knows....

From what I know about hearts, the PVCs nor ablating the RVOT will have any effect on your heart rate.  Your slow heart rate to me, seems to be related to dysautonomia.  I could be completely wrong.  I'm not a physician.

[is_something_wrong]

Itdood is completely right. Lots of PVCs is very common in dysautonomia because there is a mismatch between what your heart rate should be and what your heart rate actually is. For example, say you were doing heavy exercise at 180 bpm. If you suddenly disabled the sinus node (if it had an on and off switch), other pacemaker cells would fire, probably at 150 bpm or so, because they are stimulated by adrenaline.

In dysautonomia, you have this inappropriate brake pedal on your sinus node. It can also be opposite, if so the condition is "inappropriate sinus tachycardia" which has to do with the "gas pedal" floored at inappropriate times. Anyway, as your heart rate is 30 when it in fact should be 80, the backup pacemakers will take over. The reason why you get PVCs has also something to do with the fact that your AV node also is wired to your CNS, slowing its conduction down so much that PACs can't conduct.

The RVOT has the highest automaticity (most likely to take over as pacemaker) of all ventricular tissue. It has a beneficial location (meaning: the heart will pump more efficient if the impulse origin there instead of low down in the heart). It is by nature selected to be the pacemaker if signals from higher up in the heart for some reason are blocked or inhibited.

I can't say for sure if you do have dysautonomia (I'm not a physician) but maybe you should discuss it with a specialist?

[youngmom84]

Thank you for the information!!  

I can't say that my heart syncs with a diesel engine exactly.  I know my chest hurts around them.  Heavy bass music does cause my heart to sync with it.  It's the "bump bump bump" that changes my heart rate in dance or techo music particularly.  I can avoid concerts and night clubs, even movie theaters when the movies have lots of explosions and the like on surround sound pretty easily but the random idiot driving around "bumping" their music, I can't avoid.  Most sounds from a sub-woofer are very painful.  Since my husband is military, we live on base and the helicopters taking off nearby are painful, but I don't think I sync with them.  Coughing I do.  Have done that one several times.  But my EP is looking into the pain and syncing.  I did get diagnosed with Sinus Tachycardia in very early 2009 after the first Holter Monitor.  But I am hoping that this ablation will help with that so I'm not hunched over crying in pain because the car next to us at a red light has to be "cool".  Maybe that's a little too much hope?

[youngmom84]

Thank you!!

NCS is a form of Dysautonomia.  I've known that one since 2008.  I know it has a lot of effects on my body like blood pressure (my normal is 80s/50s) and temperature control.  I know most of my limits and triggers.  And I knew the ablation won't cure it either.  Far as I know, there is no cure for Dysautonomia.  I was on medications, but they didn't help.  Just lifestyle changes (avoiding heat, very light exercise like walking and modified yoga, paying attention to my body when I'm not feeling well, not pushing my limits, etc) and lots of salt and water or Gatorade.  By doing that, I've been able to avoid the majority of syncope episodes.  I didn't know dysautonomia could have an effect on my heart rate or even PVCs.  Does make sense though.  My recent TTT, my heart rate soared to 113.  But I was terrified at the time.  I'm horribly needle-phobic and they were trying to put in an IV.  I. Don't. Do. Needles.  So my heart rate does go up.  Seeing the EKG with a HR of 44 with PVCs is interesting.  Big spaces to begin with and bigger spaces between every 1 - 3 beats.  Had 3 different Drs watching that one, they were surprised yet amused.  Let's hope my EP doesn't have too much fun with me during the ablation. :/

I'm just ready to spend less time on the couch or in bed and more time taking my daughter outside to play or on bike rides.  I want to walk around NYC with my friends and little family and not have to worry.  Might be too much to ask, but I'll take what I can get at this point. :)

Thank you both for putting that death fear to rest.  This relative has been really good at trying to scare me with this mess and I haven't been phased until she told me it's what her cardiologist said.  Guess I know who I won't be talking to until after the procedure.  Thanks again!