Afib and pacemaker

I have had 3 ablations for atypical AVNRT since last fall. I have also had a cardioversion for afib w/rapid ventricular response. Countless EKG's have showed competing junctional rhythm since my 1st procedure. Last week my event monitor picked up a very rapid afib. It also showed burts of SVT and bigeminal PVC's. I had a 12 lead running EKG that showed the focus of the PVC's coming from the LV. My cardio/EP admitted to being very perplexed with my very complicated issue. There isn't enough space for me to put it all here. He said that the meds used to treat the afib will certainly exacerbate my junctional rhythm. So he has suggested a short course of amioderone to calm things down. He aslo mentioned ablating the AV node and placing a pacemaker. I am very hesitant to take the amioderone with all the side effects it can bring. Since Flecainide did not work I am really not to anxious to try any other antiarrhythmics, I am a 38 year old female who is desperately looking for resolution to my problems. This is drastically affecting my quality of life. I am exhausted all the time, and I am a nervous wreck to drive. My last afib attack hit while I was driving and I nearly passed out! I was fortunate to be able to pull over before this happened.

1. Do you think it is wise for me to take or not to take amioderone?
2. Do you think an AV node ablation with pacemaker is a decent option? Although it will not cure the afib. It will however allow me to take the meds that would have worsened the junctional rhythm
3. My EP also suggested doing an ablation for the PVC's. Is this any different from the ablations I had done for the SVT?

[Michael J. McWilliams, M.D.]

These are always tough situations and in my experience is never one answer as to how to treat it.

1. Do you think it is wise for me to take or not to take amioderone?

Without seeing your records and EKGs, I can't comment on whether amiodarone is appropriate.  Amiodarone can decreae PVCs and also has the best track record at decreasing atrial fibrillation.  I am reluctant to prescribe amiodarone, especially in a young person but causes like yours involving multiple arrhythmias are very tough.  

2. Do you think an AV node ablation with pacemaker is a decent option? Although it will not cure the afib. It will however allow me to take the meds that would have worsened the junctional rhythm

If I decided to use a pacemaker, I would place the pacemaker first and increase your medications. You can not get it back once it is ablated. Only if you did not respond to medications would I do an AV nodal ablation.  There is no rush to make you pacemaker dependent and you can afford to try mediations for 6 months to a year before deciding if an AV nodal ablation is appropriate.  Some people have symptoms for pacemakers and if you are one of them and you are pacemaker dependent from the AV nodal ablation, there is no way back.

3. My EP also suggested doing an ablation for the PVC's. Is this any different from the ablations I had done for the SVT?

Very different.  SVT ablation carry a very low risk of stroke.  PVC ablations on the left side of your heart carry a 1% risk of stroke and the success rates are modest, not great.  You would be a better candidate if all your PVCs or the most of your PVCs appear to be from one location.  If there are multiple locations, the success rate of a PVC ablation would be very low.

It is important to consider that there are complication risk to everything we do whether it be do nothing, medical management, and ablations.  It is a tough decision and you need to be informed about the long term consequences (stroke, being pacemaker dependent, versus living with symptoms).  You are in a tough situation and I understand the your symptoms are significant.  Don't rush into any decisions or procedures and get a second opinion if you need one.

I hope this helps and thanks for posting.