Continious Bigeminy

[ARA93]

I have now been in continous Bigeminy for 3 months. 54 yowm with long term CAD treated with stents in the past. Normal wt, N/S extremely atheletic despite my CAD. Hx of isolated PVCs forever. Had been on Atenolol 50mg for 14 years when this started. Cath last month, stents patent no other narrowing. Tried verapramil. did not work. Back on Aten 25mg . All lytes, TSH, T4, CBC, BMP normal etc. EKG unifocal bigeminy, RBBB pattern, maybe septal which means LVOT. No hypertrophy. My choice for attempted ablation or Tambocor. I am leaning toward ablation first since the rhythm is so constant, I assume this would be the best time for ablation to work if you don't have to induce it. Then, if not long term Ic class med which increases the mortality post MI 14 years ago. I have been told 70% success. 1-2 % TE risk. If I was in your office, what would you recommend? What makes the LVOT harder then the RVOT except the risk of TE vs PE ?? Thanks

[Momto3]

Sounds like you have really done your homework.  I can relate in that I faced ablations (RVOT and LVOT) a few years ago.  While the recovery periods were similar, the technical expertise of the physician was very important.

I also had a long history of persistent bigeminy and other pvc-related rhythms.  At one point the frequency led to a diagnosis of pvc-induced cardiomyopahy. I have not history of CAD, and my doctor felt comfortable prescribing tambacor.  I took it for a few months, but did not like the side effects.  Next, I was put on propafenone.  Both medications worked well at suppressing the pvcs, however, I did not really want to take 1C AA's for the rest of my life.  

I had an EPS and RFA (RVOT) in August 2003 and while I was relieved with the drastic difference in the frequency of pvcs, the doctor suggested a second procedure.  Initial evaluations pointed toward at least one additional foci (RVOT).  However, once the procedure got underway and further studies were concluded, the foci turned out to be LVOT in origin.  The foci was successully ablated and I no longer need to rely on 1C's.  If you do go ahead with the procedure, and it is successful, you will probably be amazed at how different your heartbeat will feel.  It took me some time to adjust to the normal rhythm.

Let us know what you decide.
Connie

[Michael J. McWilliams, M.D.]

You have done your research in appropriately places.  I completely agree with your assessment.

The RVOT is a straight shot from the right femoral vein to the outflow tract. There are very few impediments to catheter manipulation.  The LVOT requires arterial cannulation and the catheter goes up around the aortic arch and then down to the aortic valve.  Because of the curve in the catheter, when you turn the catheter counterclockwise, it actually moves clockwise in the heart and vice versa.  In short, it is technically more difficult.

The RVOT is thinner and it is easier to achieve closer to full thickness ablation.  If your PVCs are coming from the middle or epicardial myocardium, it can be more difficult to ablate from an endocardial approach.  There are three "layers" to the heart muscle from inside to out called endocardium, middle or M cells, and epicardium.

If you are truly in bigeminy all the time, that will make mapping much easier and increases the likelihood of success.  

The risk of pulmonary embolism is low and small emboli are filtered by the lungs.  When you are on the left side, small emboli can cause a stroke or other embolic events.  The risk is very low, but never zero.

Unless you have an ICD, I would not want to use a class Ic agent like flecainide or propafenone.  Sotalol and Tikosyn are other medical options but usually not as successful as class Ic agents.

I hope this helps.  Good luck with the procedure if you decide to proceed and thanks for posting.

[CollegeGirl143]

So great to hear such a wonderful success story.. Thank you for keeping us all updated.

[ARA93]

Ablation 3 days ago  2 hours. LVOT near the mitral valve and old scar. Continous bigeminy that never would break for 3 months, within 10 seconds of completing the ablation, NSR at 70 bpm....from 37 and bigeminy. After the procedure, I was shown the 3D mapping with the area of ablation. Pretty colors but esoteric stuff. Truly amazing. Not one PVC since. Hope it stays that way .Went home that night. Great X mas gift to me. I was happy, but my EP dr was beaming and smiling from ear to ear. 70 percent to a 100 percent . It was a great day for both of us. EP rules. Thanks for your second opinion because it made me schedule. ARA93

[ARA93]

A discription is hard. My heart rate is very slow due to the bigeimny. I can tell when it converts for short periods cause I am not aware of my heart beat. My extra beats are documented over 40k per day. You might need to do a holter.

[Manhattan]

can i ask you what bigeminy feels like? can you actually feel like a pause in between or steady popcorn popping in your chest baBoombaBoombaBoom.... i had this happen for a half hour and couldn't tell if it was just runs of pvcs or a tachycardia. thanks for your insight.

[Momto3]

I had the first procedure on a Friday and was back at work on Monday.  I should have waited a couple more days b/c I was still pretty tired.  You be able to get around pretty much as normal within a day or so, but you might be tired and a little sore.

I stayed off work for a week after the second procedure and felt much better.  

I had both ablations done in Cleveland.  If you go ahead, where will you have the ablations?  Good luck!

connie

[ARA93]

Thanks for the encouragement. What was your recovery time, and where was this done?

Thanks