Aa
Would you get a coronary stent for an ablation to fix PVCs?
I'd like to hear from people that have PVCs/stents and if they think a stent is worth the solution to fixing PVCs.
I'm male, 45 and have had PVCs I think my whole life. It used to be just every 4th beat but now it tends to be bigeminy all the time. I'm otherwise healthy, workout, my cardiologist says I have an 'athletes heart' (minus the missed beats). I don't miss beats when I workout or if I'm drinking a fair amount of alcohol, otherwise I tend to be bigeminy. I've given up caffeine, nicotine, alcohol for a time which didn't help. I was on androgel for 5 years, stopped that. I take magnesium (which helps calm the heart, not so much the beats) and try to have 2 bananas a day. I've tried fish oil and flaxseed which just make it worse. I'm almost constant bigemeny at this point, my beats drop to 35-45bpm which makes it hard to operate at work/life. I've had 6 ablations over the last 2 years:
1st, thought they found source in right ventricle. Did not ablate.
2nd, ablated near right ventricle coronary artery, no effect. I was put on sotalol for 10 months, which helped (I'd get every beat between 8 and 10AM every day) but wasn't helping so much at the end.
3rd, ablated like crazy near right coronary artery, no effect. Was put on amiodarone, which I was apparently allergic to (although for the first time in my life I did get every beat for 1 week). Was put on massive loading dose and within 3 days had my first (what I would describe as) asthma attack, massive migraine headache, itchy skin, sore throat, watery then insanely dry eyes, slight hives on neck, lasts from 4 to 8 hours. The worst part was not feeling like I was able to breathe, went to ER for the first time in my life because of this. I'm still on advair 14 months later (went from 250 to 500 back to 250 dosage, tried 100 but was getting inflammed lungs, I'll try again in a month) and the attacks come and go, usually brought on around 4 hours after working out, although it's gotten a lot better.
4th, new doctor (great guy) same hospital, found source in left ventricle 1.8mm from the top of left coronary artery. No ablation. Was put on flecainide. I tried this 4 times, every time it shot my blood pressure way up, didn't do anything for the PVCs even though I eventually lowered dose and tried for 2 weeks.
5th, tried to freeze, pierced vein, woke up intubated, lost 1.5L of blood. 2 weeks later, pericarditis, drained, hit heart, lost another .5L of blood, code blue. Anemic, ate a lot of steaks. 8 months of steroids and colchicine and the pericarditis is almost gone.
6th, ablated on inside of heart near location, no effect.
I'm now going for my 7th ablation where they are going to try low wattage, but if that doesn't work, I'd assume high wattage and they'll collapse my artery which they'll have to stent. It seems these missed beats control my life and if a stent would fix this, I'm all for it, although I'm concerned about complications.
Would you take a stent to fix PVCs?
I'm male, 45 and have had PVCs I think my whole life. It used to be just every 4th beat but now it tends to be bigeminy all the time. I'm otherwise healthy, workout, my cardiologist says I have an 'athletes heart' (minus the missed beats). I don't miss beats when I workout or if I'm drinking a fair amount of alcohol, otherwise I tend to be bigeminy. I've given up caffeine, nicotine, alcohol for a time which didn't help. I was on androgel for 5 years, stopped that. I take magnesium (which helps calm the heart, not so much the beats) and try to have 2 bananas a day. I've tried fish oil and flaxseed which just make it worse. I'm almost constant bigemeny at this point, my beats drop to 35-45bpm which makes it hard to operate at work/life. I've had 6 ablations over the last 2 years:
1st, thought they found source in right ventricle. Did not ablate.
2nd, ablated near right ventricle coronary artery, no effect. I was put on sotalol for 10 months, which helped (I'd get every beat between 8 and 10AM every day) but wasn't helping so much at the end.
3rd, ablated like crazy near right coronary artery, no effect. Was put on amiodarone, which I was apparently allergic to (although for the first time in my life I did get every beat for 1 week). Was put on massive loading dose and within 3 days had my first (what I would describe as) asthma attack, massive migraine headache, itchy skin, sore throat, watery then insanely dry eyes, slight hives on neck, lasts from 4 to 8 hours. The worst part was not feeling like I was able to breathe, went to ER for the first time in my life because of this. I'm still on advair 14 months later (went from 250 to 500 back to 250 dosage, tried 100 but was getting inflammed lungs, I'll try again in a month) and the attacks come and go, usually brought on around 4 hours after working out, although it's gotten a lot better.
4th, new doctor (great guy) same hospital, found source in left ventricle 1.8mm from the top of left coronary artery. No ablation. Was put on flecainide. I tried this 4 times, every time it shot my blood pressure way up, didn't do anything for the PVCs even though I eventually lowered dose and tried for 2 weeks.
5th, tried to freeze, pierced vein, woke up intubated, lost 1.5L of blood. 2 weeks later, pericarditis, drained, hit heart, lost another .5L of blood, code blue. Anemic, ate a lot of steaks. 8 months of steroids and colchicine and the pericarditis is almost gone.
6th, ablated on inside of heart near location, no effect.
I'm now going for my 7th ablation where they are going to try low wattage, but if that doesn't work, I'd assume high wattage and they'll collapse my artery which they'll have to stent. It seems these missed beats control my life and if a stent would fix this, I'm all for it, although I'm concerned about complications.
Would you take a stent to fix PVCs?
COMMUNITY LEADER
Nah taking blood thinners is probably going to do more good (preventing in stent stenosis) then harm (hemmorhage).. Should the artery be damaged that is.
COMMUNITY LEADER
Any new info on this case? Is op still comin through from time to time?
This is a tough situation, a significantly complicated ep case dont forget to keep us posted!
This is a tough situation, a significantly complicated ep case dont forget to keep us posted!
1 Comments
Thanks again for the responses. I have my ablation scheduled in 2 days and still need to talk to the doc about the game plan. I know he is at least going to try low wattage ablation 1.8mm from the top of the left coronary artery hoping to ablate the pvcs without collapsing the artery. If the low wattage doesn't work then I'm not sure if he is going with the high wattage/collapse artery/stent option or not. I'll take the stent if it fixes pvcs and I don't have any other complications (blood thinners for 6 months?). I'm not sure what my other options are (back on sotalol but higher dose? that helped but I still had a lot of pvcs, try flecainide for the 5th time? that didn't seem to help at all), all I know is I can't keep going on like this. My life quality is subpar and I'm afraid I'll get canned from work (they've been more than cool over the last year but I can't excel at work with 35-45bpm not to mention the palpitations/flipflops which make it hard to concentrate on what's at hand).
There are lots of yellow flags about the skills and experience of the doctors performing your PVC ablations. First off, high density mapping is needed before any burning and you don't burn anywhere near arteries. That is asking for trouble. You also mentioned the use of cryocathers to freeze suspected triggers. I presume that is done because of catheter tip stability considerations. Usually, that is used for AVNRT ablation where the sinus node is close by and the doctor is trying to minimize the risk of heart block. I have never heard of it being used to ablate PVCs or VTs because it lacks flexibility and PVCs can come from difficult to reach spots. My suggestion for you is to seek out an ablationists that do a lot of PVCs every year and have a lot of procedures under their belt. The top centers will have EPs that specialise in PVCs ablations. Look at St Davids in Austin and Intermountain in SLC. Those are the closest top PVC/VT centers to you with the volume and skills. Best of luck and sorry you have to go through what you have experienced. Doctors need to know when skills required exceed their training.
2 Comments
I wouldn't even go so far as to say cryroablation would be good for avnrt either researcher.
Its just all around not as effective at delivering lesions. Simply being caught in possession of a cryroablation system is a yellow flag. :D
I love how blunt you are though man, dang!
I didnt ask but i was hoping his issue with the cryroablation has more to do with the procedure being done several years ago when that was still the hot thing.
Personally ive never actually seen one.. Only read about them.. And heard horror stories.
Its just all around not as effective at delivering lesions. Simply being caught in possession of a cryroablation system is a yellow flag. :D
I love how blunt you are though man, dang!
I didnt ask but i was hoping his issue with the cryroablation has more to do with the procedure being done several years ago when that was still the hot thing.
Personally ive never actually seen one.. Only read about them.. And heard horror stories.
You forgot "ablating in the wrong spot" as a yellow flag.
That certainly doesnt seem too easy in a pvc ablation.. Granted im not an electrophysiologist..
But.. If youre mapping, and find the earliest impulse, and confirm it with egms and pacing and surface ecg.. Then after placing the lesions you monitor to ensure the pvc's terminated.. After going through all that it should be difficult to send a patient home with the same pvc.. Unless youre cryroablating apparently.
To play devils advocate though, the fact that this patient has been through several studies that didn't result in an ablation is a green flag. That tells me that electrophysiologists have looked at this thing in the past and were uncomfortable burning it. So it is possible that the pvc is located in a very anatomically inconvenient location (epicardial and close to the coronary)..
If pursuing a second opinion with a physician more specialized in pvc ablation i would STRONGLY recommend trying to export as much of the 3D mapping data as possible and sending it in advance. I'm not sure exactly how this would work logistically, but if they call their reps they should know.
That way youre not going halfway across the country for a study only to get the same story you got at home.
That certainly doesnt seem too easy in a pvc ablation.. Granted im not an electrophysiologist..
But.. If youre mapping, and find the earliest impulse, and confirm it with egms and pacing and surface ecg.. Then after placing the lesions you monitor to ensure the pvc's terminated.. After going through all that it should be difficult to send a patient home with the same pvc.. Unless youre cryroablating apparently.
To play devils advocate though, the fact that this patient has been through several studies that didn't result in an ablation is a green flag. That tells me that electrophysiologists have looked at this thing in the past and were uncomfortable burning it. So it is possible that the pvc is located in a very anatomically inconvenient location (epicardial and close to the coronary)..
If pursuing a second opinion with a physician more specialized in pvc ablation i would STRONGLY recommend trying to export as much of the 3D mapping data as possible and sending it in advance. I'm not sure exactly how this would work logistically, but if they call their reps they should know.
That way youre not going halfway across the country for a study only to get the same story you got at home.
COMMUNITY LEADER
Well, based on your description of the reaction it sounds like what you were experiencing was amiodorone induced pulmonary toxicity which is typically symptomatic.. It sounds like they did all the right things to treat it but to no avail. This is jot an allergy per se but just a bad response to the tixic effects of amio.
It effects in everyone who takes it to some degree, and is referred to as "the amiodorone effect". In most folks however they are asymptomatic or experience only occasional mild discomfort. Respiratory distress that doesnt react to treatment is pretty uncommon.
That said the amiodorone effect is so named because it effects patients taking amiodorone almodt exclusively, so theres no need to be nervous about other drugs.
Flecainide is by far the most effective thing youve tried statistically speaking (aside from amio).. If you had a hypertensive response that could be combatted with aggressive management and volume control.
Cryroablation is just all around not what it was cracked up to be a few years ago.. Use of cryroablation wasnt necessarily,the cause of your complications per se.. However it may explain why you went throigh all that for nothing.
It effects in everyone who takes it to some degree, and is referred to as "the amiodorone effect". In most folks however they are asymptomatic or experience only occasional mild discomfort. Respiratory distress that doesnt react to treatment is pretty uncommon.
That said the amiodorone effect is so named because it effects patients taking amiodorone almodt exclusively, so theres no need to be nervous about other drugs.
Flecainide is by far the most effective thing youve tried statistically speaking (aside from amio).. If you had a hypertensive response that could be combatted with aggressive management and volume control.
Cryroablation is just all around not what it was cracked up to be a few years ago.. Use of cryroablation wasnt necessarily,the cause of your complications per se.. However it may explain why you went throigh all that for nothing.
COMMUNITY LEADER
As if that post wasnt enough.. 3 more questions for ya..
1. Any family history of heart problems, specifically ovcs or sudden death?
2. Have you ever been told you have any bundle branch problems?
3. Have you ever been consulted about genetic testing?
1. Any family history of heart problems, specifically ovcs or sudden death?
2. Have you ever been told you have any bundle branch problems?
3. Have you ever been consulted about genetic testing?
2 Comments
https://www.ncbi.nlm.nih.gov/pubmed/17403077
Thanks for the quick and detailed response. I should have said ablation procedures, they actually only ablated 4 out of the 6 times. The first 3 procedures were done with a doctor who apparently had the wrong source. The 4th, new doctor, they found the source but it was just in a really bad spot. I think my pvc's are single focus and just from that one spot from what I understand. It's also apparently on the outside of the heart and not the inside, so they were using a vein to get close to it to hit it (which is the vein that was pierced by the larger cryo tip when they were attempting to freeze).
My dad was allergic to iodine or at least the contrast dye for when he had a cardiac stent put in about 15 years ago. I mentioned to the hospital that I might be allergic to iodine as well, but I haven't had a problem with contrast dye yet, during a CAT scan and all these procedures (I assume they use some sort of contrast dye). I did read somewhere that contrast dyes have changed over the years though so maybe less of a reaction? As for the amiodarone, they did a loading dose in the hospital that was IV and then I did about 2 days of pills. Right away during the IV phase my lungs felt tight the entire time but I really didn't feel like I couldn't breathe til about 2 days later. I'm not sure if it was an anaphylactic reaction or what. It tends to come and go in waves of 4 to 8 hours and I can definitely set it off if I do something like workout or just jog for 10 minutes (the attack will hit 4 hours later). 3 weeks into this I went to ER for the 2nd time in my life and was given steroids, felt great for 2 days and then bam, the worst attack yet. For 8 hours all night long I felt like I was having something like an asthma attack (I don't have asthma). At that point I contacted my doctors and was put on advair 250. From then on, even if I got an attack and my lungs flared up, I felt like I could still breathe thru it. A month later I was moved up to the 500 dose and that mostly fixed my lung problems (I still got the itchy skin, tearing then dry eyes, splitting headache's during an attack, heart palpitations and at first when it was really bad, I'd also have a sore throat, slight hives on neck and I'd have to defecate about 1 hour before an attack hit, lol). 6 months ago I tried to lower to 250 and got nothing but inflammed lungs, 1 month ago I did it no problem. 2 weeks ago I tried to go to 100 but was getting the inflammed lungs again so I'm going to wait a little more. It's slowly, and I mean slowly, getting better to now I'll get an attack and I'm not quite sure if I'm having one or not. It's been 14 months! I'm not going near amiodarone again. They did mention the version without iodine, but I'm leery of even taking that.
I've tried other meds that didn't help the pvcs like diltiazem (made me dizzy for a week), beta blockers, lidocaine, rythmol, sotalol (for 10 months, helped with beats although didn't get rid of it, slowed my heart rate to 35bpm when in bigemeny and was working less and less at the end). Although honestly, after the amiodarone and dealing with all that I didn't give a lot of these medications much of a chance, a day to a week tops. I did try flecainide a couple times at my doctors urging but that shot my blood pressure up to 188/110 and I ended up going to ER for the 3rd time in my life. I also wasn't sure what was reacting with the amiodarone attacks. After the amiodarone I sort of lost trust in what meds were being fed to me.
They did MRI's, CAT scans, echo's all that showed my heart was structurally sound. They haven't really mentioned a pacemaker yet.
Family history, yes my dad had to have a stent put in but he also had cancer so we aren't sure if all the meds and radiation treatment might have had something to do with it. I do tend to have higher cholesterol, and they did mention that I had a 40% blockage of my widowmaker and I was put on statins, which I don't behave well with. I've stopped taking them until I can get the pvcs sorted out. I also had an uncle with heart issues but not sure exactly what the problems were, it wasn't pvcs. I should have mentioned earlier, I have an identical twin brother who doesn't have a problem with pvcs either.
So if they can fix it, but they'd have to collapse the artery to do it and put a stent in, what exactly would that do to my life quality? After blood thinners for 6 months to a year couldn't I live a normal life? The doctor doesn't want to do it, but hell yah sign me up if it'll get rid of these pvcs.
My dad was allergic to iodine or at least the contrast dye for when he had a cardiac stent put in about 15 years ago. I mentioned to the hospital that I might be allergic to iodine as well, but I haven't had a problem with contrast dye yet, during a CAT scan and all these procedures (I assume they use some sort of contrast dye). I did read somewhere that contrast dyes have changed over the years though so maybe less of a reaction? As for the amiodarone, they did a loading dose in the hospital that was IV and then I did about 2 days of pills. Right away during the IV phase my lungs felt tight the entire time but I really didn't feel like I couldn't breathe til about 2 days later. I'm not sure if it was an anaphylactic reaction or what. It tends to come and go in waves of 4 to 8 hours and I can definitely set it off if I do something like workout or just jog for 10 minutes (the attack will hit 4 hours later). 3 weeks into this I went to ER for the 2nd time in my life and was given steroids, felt great for 2 days and then bam, the worst attack yet. For 8 hours all night long I felt like I was having something like an asthma attack (I don't have asthma). At that point I contacted my doctors and was put on advair 250. From then on, even if I got an attack and my lungs flared up, I felt like I could still breathe thru it. A month later I was moved up to the 500 dose and that mostly fixed my lung problems (I still got the itchy skin, tearing then dry eyes, splitting headache's during an attack, heart palpitations and at first when it was really bad, I'd also have a sore throat, slight hives on neck and I'd have to defecate about 1 hour before an attack hit, lol). 6 months ago I tried to lower to 250 and got nothing but inflammed lungs, 1 month ago I did it no problem. 2 weeks ago I tried to go to 100 but was getting the inflammed lungs again so I'm going to wait a little more. It's slowly, and I mean slowly, getting better to now I'll get an attack and I'm not quite sure if I'm having one or not. It's been 14 months! I'm not going near amiodarone again. They did mention the version without iodine, but I'm leery of even taking that.
I've tried other meds that didn't help the pvcs like diltiazem (made me dizzy for a week), beta blockers, lidocaine, rythmol, sotalol (for 10 months, helped with beats although didn't get rid of it, slowed my heart rate to 35bpm when in bigemeny and was working less and less at the end). Although honestly, after the amiodarone and dealing with all that I didn't give a lot of these medications much of a chance, a day to a week tops. I did try flecainide a couple times at my doctors urging but that shot my blood pressure up to 188/110 and I ended up going to ER for the 3rd time in my life. I also wasn't sure what was reacting with the amiodarone attacks. After the amiodarone I sort of lost trust in what meds were being fed to me.
They did MRI's, CAT scans, echo's all that showed my heart was structurally sound. They haven't really mentioned a pacemaker yet.
Family history, yes my dad had to have a stent put in but he also had cancer so we aren't sure if all the meds and radiation treatment might have had something to do with it. I do tend to have higher cholesterol, and they did mention that I had a 40% blockage of my widowmaker and I was put on statins, which I don't behave well with. I've stopped taking them until I can get the pvcs sorted out. I also had an uncle with heart issues but not sure exactly what the problems were, it wasn't pvcs. I should have mentioned earlier, I have an identical twin brother who doesn't have a problem with pvcs either.
So if they can fix it, but they'd have to collapse the artery to do it and put a stent in, what exactly would that do to my life quality? After blood thinners for 6 months to a year couldn't I live a normal life? The doctor doesn't want to do it, but hell yah sign me up if it'll get rid of these pvcs.
COMMUNITY LEADER
Yeah ablate away. Anyways wtf.. This is one of those stories i feel like im missing some information in.
You go through all these ablations.. Each ablation they should be trying to burn as many focal points as they can...
You keep getting more.
The only drug that helps is amiodorone which you're allergic to.. Annddd stop.. Hammer time!
You're probably not allergic to amiodorone... I say again.. No.. Allergy. There are 2 options here..
1. Youre allergic to iodine, which is a component of amiodorone. If this was the case you'd have reactions to shellfish and contrast media and other things... Such as well.. Iodine.. Your whole life. Even so, patients with documented iodine sensitivity never react to oral amiodorone in studies, but there is a theoretical possibility for a reaction.
2. (Most likely explanation) You're allergy is likely to one of the fillers/cosolvents in amiodorone. At which point i would be curious to see if theres some alternative with a slightly different composition that would work.
Out of curiosity were you loaded on amiodorone intravenously or orally? I would be curious to see how you react to the iv version of the drug.. Also if your reaction was maybe something that was evident while taking the very large loading dose (600mg - 1.2 grams), but may resolve on a lower dose. A small infusion can be started to observe tolerance, if poorly tolerated you could always load the patient up on steroids then tour de france and see how they tolerate from there.
If amiodorone (which is a damn miracle drug for basically every arrhythmia btw, im not suprised it worked...) Was successful.. And youve been through 7 ablations, to include a complicated one.. My focus would be figuring out how to feed you some amiodorone!
Also relevant here.. What sort of reaction did you have exactly? Anaphylactic?
If you bust out with amiodorone, you can try a plan b.. Start trialing more obscure drugs in the same class that are available orally..
Unfortunately corvert is IV only.. Which is a shame because this would be the first go to.. I wonder if anyones ever studied subq or im administration.. I found some bits and pieces saying IM is effective in animals.. But what a damn shame they don't have a set up for people.. That way you could just take a shot at home similar to how a diabetic administers,insulin.. Except youd be controlling pvc's. Ask your EP why they don't have IM ibutilide in the world.. I wonder what his take on it is..
Anyways with ibutilide out of the way that leaves:
Dofetilide
Dronedarone
If available **rare meds** either may supress your pvcs if you had success with amio. Downside here is theres alot of contraindications.. But its worth seeing if you qualify.
*phew* wipes sweat.. Moving on!
So all these ablations.. But what doesnt make sense here is why.. Theres just no reason why you should,go through this many.
Either they havent ablated properly, or they've been kind of sloppily knocking back the dominant foci without focusing on other potentially problematic 'early' areas.
Possible, but that doesnt make sense either.. No ep professional is so wreckless as to have to go back over his work 7 times..
So that leaves another possibility...
Genetic arrhythmogenic pathology... More specifically...
Arvc/d
Arrhythmogenic right ventricular cardiomyopathy/dysplasia
Sorry but, rare or not 7 ablations later the glove sort of fits.. Have you ever had an endomyocardial biopsy? How do your echos look? You said the pvcs have been isolated on the right side before?
Something is just seriously wrong here.. Likely Structurally that needs some explaining..
As for the topic at hand.. Sure get the ablation.. But at some point someone has to identify an underlying cause to this refractoryness... Going back for repeat ablations is going to inevitably create reentrant substrate that will put you at risk for sudden cardiac death. You may be a candidate for icd placement already given the history.
Which brings me to my next point, how refractory is the tissue to pacing? Can they overdrive suppress these pvcs? Are they behaving as escape beats, if so can they just be paced? BiV ICD setup with aggressive medical management? If so theoretically you could just pace the whole system and be done with it.
Many questions, many theories to ponder.. I look forward to a response with hopefully some more information!
You go through all these ablations.. Each ablation they should be trying to burn as many focal points as they can...
You keep getting more.
The only drug that helps is amiodorone which you're allergic to.. Annddd stop.. Hammer time!
You're probably not allergic to amiodorone... I say again.. No.. Allergy. There are 2 options here..
1. Youre allergic to iodine, which is a component of amiodorone. If this was the case you'd have reactions to shellfish and contrast media and other things... Such as well.. Iodine.. Your whole life. Even so, patients with documented iodine sensitivity never react to oral amiodorone in studies, but there is a theoretical possibility for a reaction.
2. (Most likely explanation) You're allergy is likely to one of the fillers/cosolvents in amiodorone. At which point i would be curious to see if theres some alternative with a slightly different composition that would work.
Out of curiosity were you loaded on amiodorone intravenously or orally? I would be curious to see how you react to the iv version of the drug.. Also if your reaction was maybe something that was evident while taking the very large loading dose (600mg - 1.2 grams), but may resolve on a lower dose. A small infusion can be started to observe tolerance, if poorly tolerated you could always load the patient up on steroids then tour de france and see how they tolerate from there.
If amiodorone (which is a damn miracle drug for basically every arrhythmia btw, im not suprised it worked...) Was successful.. And youve been through 7 ablations, to include a complicated one.. My focus would be figuring out how to feed you some amiodorone!
Also relevant here.. What sort of reaction did you have exactly? Anaphylactic?
If you bust out with amiodorone, you can try a plan b.. Start trialing more obscure drugs in the same class that are available orally..
Unfortunately corvert is IV only.. Which is a shame because this would be the first go to.. I wonder if anyones ever studied subq or im administration.. I found some bits and pieces saying IM is effective in animals.. But what a damn shame they don't have a set up for people.. That way you could just take a shot at home similar to how a diabetic administers,insulin.. Except youd be controlling pvc's. Ask your EP why they don't have IM ibutilide in the world.. I wonder what his take on it is..
Anyways with ibutilide out of the way that leaves:
Dofetilide
Dronedarone
If available **rare meds** either may supress your pvcs if you had success with amio. Downside here is theres alot of contraindications.. But its worth seeing if you qualify.
*phew* wipes sweat.. Moving on!
So all these ablations.. But what doesnt make sense here is why.. Theres just no reason why you should,go through this many.
Either they havent ablated properly, or they've been kind of sloppily knocking back the dominant foci without focusing on other potentially problematic 'early' areas.
Possible, but that doesnt make sense either.. No ep professional is so wreckless as to have to go back over his work 7 times..
So that leaves another possibility...
Genetic arrhythmogenic pathology... More specifically...
Arvc/d
Arrhythmogenic right ventricular cardiomyopathy/dysplasia
Sorry but, rare or not 7 ablations later the glove sort of fits.. Have you ever had an endomyocardial biopsy? How do your echos look? You said the pvcs have been isolated on the right side before?
Something is just seriously wrong here.. Likely Structurally that needs some explaining..
As for the topic at hand.. Sure get the ablation.. But at some point someone has to identify an underlying cause to this refractoryness... Going back for repeat ablations is going to inevitably create reentrant substrate that will put you at risk for sudden cardiac death. You may be a candidate for icd placement already given the history.
Which brings me to my next point, how refractory is the tissue to pacing? Can they overdrive suppress these pvcs? Are they behaving as escape beats, if so can they just be paced? BiV ICD setup with aggressive medical management? If so theoretically you could just pace the whole system and be done with it.
Many questions, many theories to ponder.. I look forward to a response with hopefully some more information!
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