post-ablation for SVT with PVCs and breakthrough

Hi, I am a 36-yr-old female who had ablation for SVT in November 2011.  I have had SVT since age 20, and decided to have an ablation for a number of reasons.  First, the SVT was worse as I got older (not usually lasting more than a few minutes but often at 240 bpm +), I had a terrible time with it at the end of my pregnancy and an even worse episode during labor that required two doses of adenosine.  Dealing with it and a newborn became stressful.  The ablation went very well and my doctor was convinced I was cured.  I had cryoablation, the procedure did not last long because my heart cooperated, and there were three freezes made in the troublesome spot.  My doctor is very experienced and has performed thousands of RF ablations and hundreds of cryoablations.  He believes the effectiveness of cryoablation if comparable to RF ablation when the right size tip is used, I believe. However, I started having strange sensations in July.  I now believe they were terrible PVCs (have had them before, not too often, but never felt the way they did in July), the kind that make you think you are going to pass out.  After one particularly bad one, I had a breakthrough of SVT which did not last long.  I have been wearing an event monitor for almost 6 weeks.  I have caught one or two runs that lasted 5 beats or less - not as long or as fast as the breakthrough.  But over the last week I am getting many PVCs a day (not many for some people, but for me - perhaps dozens a day?), not the terrible ones though.  I feel that something has clearly changed since July.  Before that I felt the occasional PVC which ended in a thud, and I was not bothered and was so thankful for the ablation.  Now I feel uncertain of what is going to happen next.  I am worried that the ablation is causing other problems.  I am making lots of recordings on my monitor, and every time I download them I am told that there's nothing to alert the doctor for.  I am seeing my EP in less than a week.  I have many questions written down to ask, but are there any suggestions for questions or any thoughts that you might have?

[tom_h]

There must have been a good reason why the physician chose cryoablation over RF ablation as it seems to be a general opinion that cryo isn't as effective as RF.  This was also the opinion of my electrophysiologist when I asked him which method was going to be used for my ablation.

As for your breakthroughs, it's not uncommon for these to occur for up to and beyond a year after the procedure.  I when through a period of cardiac restlessness 8 months after mine.  I awoke one evening to frequent PVC's and 3 to 5 beat runs of what felt like SVT.  This went on for about 2 weeks whenever I did any exertion.  Then one day it vanished.  Then the PVC clusters I had for the last 7 years disappeared as well.  I still get occasional 5-10 beat runs of SVT, but these drop out on their own, requiring no intervention on my part.  My cardiologist believes there might be a small thread of conductive tissue remaining, and this could be your case as well.  I think unless it's debilitating to you, I'd give it a little more time before going in again.  You report above indicates that during your monitor period, you have experienced two runs.  To me that would be an acceptable number, especially for us who have hearts which are prone to this problem anyway.  You may eventually have to go in again, as I may someday.  In the meantime, I continue to revel in being able to push myself well beyond what the average 62 year old male can do without the spectre of SVT constantly persuing me.  I hope it works out for you as well.

[CS3218]

Thanks for your input, Tom.  

My EP told that I would continue to feel skipped beats, but we never discussed that it would be normal to have runs after the procedure.  He told me to call the office if I had further runs. I will certainly ask about this.

I have AVNRT, and my doctor prefers to use cryoablation when possible for AVNRT to avoid the 1% chance of damaging the AV node and having to insert a pacemaker.  Certainly he used RF before cryo technology, but his results with cryo have been as good or near as good as with RF.  I did hear that cryo was not as effective from another EP that visited me in the hospital once, but he was not as experienced as my doctor so wan't sure what to believe.

I'm glad to hear you are doing well.  I read your journal and saw that you said you had two types of runs, one where you can feel the runs on top of your regular beat.  I may have been experiencing something like this since my procedure (never before).  I actually thought it was a muscle spasm and I'm still not sure it's my heart.  I have made some recordings of it so we will see.  I thought I felt it right after the ablation while in the hospital still, but the nurses did not detect a significant change in rate.

Thanks again!

[tom_h]

Well the beauty of cryo of course is that you can try it before burning it, and there is certainly an advantage to that.

As you might have read, I had nearly a lifetime of AVRT.  The area burned was in the left atria just above the valve.  A wide conductive area was bridged with 17 connected burns.

That SVT over normal sinus rhythm was a wierd phenomenon.  I could palpate my pulse in my wrist and feel the normal beat, while I could feel the SVT in my chest.  Within less than 10 seconds though, the SVT would take over.  Occasionally, I could disrupt it with a firm cough and return to NSR. I would have loved to have seen what a trace of that looked like.  For years my cardiologist pleaded with me to come to the ER immediately for an EKG when I had an event, and I had countless opportunities to do so as my SVT was self sustaining and never dropped out on its own.  But it was such a fast rate, and that "cinder block on the chest" feeling bothered me, so I always terminated them as quickly as I could.  Finally he suggested a 30 day monitor, and that did the trick in catching 3 events in one month.

[michellepetkus]

I also had avnrt. I had a super bad case of pvcs about 5 weeks after my ablation where I was getting over 10,000 a day and for a full year I was getting hundreds and I too feel very short runs of something but it may actually not be the svt but pacs or pvcs.  So long as you are not falling into a full blown tachycardia event no matter what it is you are likely OK.  Your heart will never be perfect.  My EP basically told me I would never get rid of the pvcs but I should stop feeling them.  It took a year.  They are calm now to where I only feel a couple throughout the day but I also know for whatever reason they can flare up from time to time throughout our lives.  Why I don't think anyone knows but it sounds like this happened with you.  And from what I understand they could stop just as suddenly.  I would say when you get a bad bout of them try coughing a bit to see if you can shake them loose.  I think much like the svt they can get kind of stuck in a pattern as well.  From what my ep told me about cryo he liked to use it to test the bad spot initially in case there was a chance of a block so he could stop and the heart could recover but if the spot was safe he would use the RF to be more effective. Though according to my report my spot was far enough away when he discovered where it was he probably had no reason to worry and just used the RF right off the bat.  That said, it if turns out your heart is recovering from the cryo I am sure a second ablation would correct any issues though again unless you are having full blown episodes you may not need to worry.  If you start to pass out or have other troubling issues then there is definitely a need to take action but otherwise you may have no need to worry.  Take care and please do keep us posted on your results.  

[CS3218]

Thanks for the comments.
Upon looking at my monitor results, my EP thought the short runs were another kind of SVT (not AVNRT).  He said this is common and explained where in the atrium it usually originates in young women like myself.   While it can be ablated, he said most people do not find it bothersome as it is not the kind of SVT that puts one in the emergency room.  It requires a different mapping system, so they are not even looking for it when they ablate for AVNRT.  However, when I described the event that made me call in the first place (a short run of what felt like my old SVT preceded by a terrible PVC or PAC), he told me he could not rule out a recurrence as there is always a 3-5% chance of it returning.  If it was a recurrence of the AVNRT, then he said it would eventually return (so I guess he does not think breakthroughs are normal).
I am still having bad days with many PVCs and PACs, and I am concerned that the ablation caused them.  My doc said that post-ablation many people do have an increase in them, but they calm down after a few months.  So there is not really an explanation for why I am getting them now, almost a year later.  I would love some reassurance that they will subside, even if they do return for spells.  My EP has PVCs that come and go and sometimes affect his breathing, but he deals with them because he knows they will not kill him.  I did ask about long-term problems after a “successful” ablation, and he said there aren’t any except for the rare occasion with RF ablation when someone’s heart rate can increase significantly upon mild exertion.  He said this had not been reported with cryo.  
Also, I learned that the “muscle spasm” feelings I get are just that, like a muscle twitch you get in your eye.  My EP has those too and explained them in detail, most of which I have now forgotten.

[CS3218]

Hi Michelle,
I posted again with an update but I think I messed up the "to" field, and I wanted to say thank you for your comments.

[michellepetkus]

You are welcome.  I am a year out from my ablation and I have to say what is clear to me is my heart will never be normal.  The pacs and pvcs are a lot calmer now though it took a year for them to calm down but I still can feel them pretty strong from time to time and some out right hurt but it passes pretty quickly and when I am busy I do notice them less but they do make me very aware when I am stressing out.  I also get short runs of something though I suspect the are likely runs of pacs or something like that rather than avnrt.  It lasts for 5 or so seconds only so it isn't a concern but my heart can get riled up fairly easy.  That said, if yours are as strong as they were right after the ablation it may be due to the fact that you still have bouts of svt or it could simply be where they are located.  Sometimes when they get going they can just have a mind of their own. And like I said before if the pvcs are getting really bad really see if you can jar them loose by cough or something.  I really do think they kind of get stuck in a pattern like the svt did.  Everyone's heart is different.  Mine took a really long time to recover. Maybe you just need a little more time.  Well keep an eye on things.  Hopefully your ectopics will ease up for you soon and your runs of whatever never progress past little short bursts.  I do hope you feel better soon.  Take care.

[CS3218]

Hi Michelle,

Are your pacs and pvcs still relatively calm?  I hope so.  I thought mine were calming but have been acting up again.  Funny thing is, while I did get some after the ablation, they were not many.  They did not get worse until 8 months later after I *thought* I had a breakthrough.  I wonder now if it was sinus tachycardia?  Is a bad bout of pacs or pvcs likely to precede that?

[CS3218]

Hi Tom,

I posted an update a while back but messed up to '"to" field so you probably did not see it. In a nutshell, my doc's impression from my tape was that my short runs were another form of SVT, I believe since the rate was only 150-160 and now I see that is not characteristic of AVNRT.  My runs prior to ablation were usually very fast, but I did rarely get a slow run and I just assumed it was all the same.

That leaves me wondering about the event that prompted me to call the doc in the first place, which to me seemed like very bad pacs or pvcs followed by a run of my original AVNRT.  Well, it felt similar, faster than 150 but probably not as fast as I am used to, but more muted.  I have not experienced that again and that was almost 4 months ago.  My AVNRT used to strike every 2-3 weeks, usually in clusters over 1-3 days but stopped after seconds to minutes.  I am wondering if it could have been sinus tachycardia?

I was also wodnering, since you seem well-versed, what is the difference between AVNRT and AVRT?

I am still troubled by daily pvcs and pacs and do need to have some hope that they will diminish.  I do not mind a few a day, as I felt after the ablation, but I am really tired of the dozens and dozens I get some days since having what I thought was the recurrence.  I know that is not a lot for some but it is a lot for me and I have trouble coping some days.  My doctor says that "successful" ablations do not cause long-term problems, but I don't think he considers ectopics a problem.  To him they are normal.  I am praying that the ablation did not cause chronic ectopics.  Do you think this is even possible?

[tom_h]

"I was also wondering, since you seem well-versed, what is the difference between AVNRT and AVRT?"

I'm not an expert, but I'll give it my best shot.  I'll have to post this in 2 parts.

AVNRT

The distinction between atrioventricular node re-entrant tachycardia (AVNRT) and atrioventricular reciprocating tachycardia (AVRT) is sometimes difficult to diagnose by examining a patient EKG.  AVNRT is five times more common that AVRT, so naturally the diagnosis favors the former.  For some reason it also favors females to males by 75%.  AVNRT occurs when a reentry circuit forms within or just adjacent to the AV node. The circuit usually involves two pathways.  There's a fast pathway and the slow pathway, both of which are ilocated in the right atrium. The slow pathway is the one usually targeted for ablation(which is usually targeted for ablation.  These pathways are formed from tissue that behaves very much like the AV node, and some physicians actually regard them as part of the AV node.

[tom_h]

AVRT

AVRT contains a number of different disorders commonly referred to as "pre-excitation syndromes".  WPW is a well known type of AVRT and is commonly interchanged by someone who has discovered they have SVT.  AVRT is caused by the presence of an abnormal accessory electrical conduction pathway between the atria and the ventricles. Electrical pulses travelling down this abnormal pathway known as the bundle of Kent may stimulate the ventricles to contract prematurely, resulting in this type of supraventricular tachycardia. The direction it conducts will indicate if it is Wolff-Parkinson-White, or some other form one of which I had called Circus Motion Tachycardia, a tight circular circuit resulting in extremely high heart rates.  As a 6 year old kid, I was once recorded in a hospital at 312 bpm.  I believe AVRT can form on either side of the heart, but mine was on the left side in the atria near the valve.  It was a wide area of conductive tissue that created a very reliable circuit and as I experienced, once started, it would self sustain itself never dropping out on its own.

So as you can see, perhaps your EP physician decided on cryo-ablation due to the location of your problem site with respect to the AV node.  Mine was located well away from that area.

[horseluver4]

My answer to your question would be yes. an ablation can cause lingering long term pvc pac, i had 2 Ablations and now more than ever am having pvc and pac's, i am on atenolol and rythmol and still having break through days of pvcs and pacs, i get up to 20,000 in a 24 hour period. I would give my right arm too only have a hundred a day. Uhggg these are very hard to live with and at times can be debilitating. My quality of life has really went down hill each year as they have gotten worse. I may consider another ablation however am skeptical it may just open a whole new can of worms to a new worse rhythm. I don't even know if there is such ablation for JUST pvcs and pacs. Anybody know? And yes asset my last Ablations my heart was really really irritated and did weird beats for a few months. No fun

[horseluver4]

Oh by the way my Ablations were done in 2002 & 2004. Then was better for many years now I'm worse than ever almost 10 years later. :(

[ocmama24]

Hi,

I've had 2 RF ablations for my AVNRT.  Unfortunately, they were both unsuccessful and I may be heading in for a third.  Anyway, I just wanted to let you know that even though the ablations didn't work they did change the rates of my episodes.  I used to have runs at 240bpm.  Now when I have them they are between 160-180. My doctor said its the same SVT coming from the same area.  There is always the chance that you could have the same arrhythmia and not a new one.  Either way, it ***** to have to deal with any kind of arrhythmia after an ablation.  I hope your appointment goes well and that you are able to find out what's going on with your heart.  Keep us posted!

[Alexandrarose22]

This thread is older now but I figured I would post anyway! I also had AVNRT and had a RF ablation 11 months ago. The procedure only took three hours and he only had to burn 2 times to kill the pathway. When I woke up he told me I was cured, but that I would get PAC's the rest of my life. I felt really good the first few weeks and then all of a sudden I started getting hundreds to thousands of PAC's a day. Some days they weren't so bad but others felt really scary and made me have anxiety (which makes the PAC's even worse) I went in to see my Doctor and he caught a few on my EKG and he confirmed they were just PAC's, and told me that they may last months and are normal for me. For about six months after my ablation I had severe PAC's, but out of nowhere they just stopped.  I was PAC free (almost) until about a month ago and they are back.  I am now in medical school (which is super stressful) and have learned a whole lot about the heart.  This is what I think of PAC's:

1.) They are brought on by stress, alcohol, lack of sleep, anxiety, if you are ill with a fever they get worse, caffeine, and for women getting your period can make them worse.  
2.) They are completely BENIGN and are not life threatening although I know they are scary.  A PAC is simply extra calcium being stored in your myocytes (heart cells) so that your next beat or few next beats are stronger then normal.  
3.) My Doctor had a great analogy that helped me understand the PAC/SVT relationship......Think of your extra pathway as the gasoline that fuels a car, our Doctors took all the gasoline out of the car so that it cant "start" The PAC's are like trying to start the car (turning the ignition) but since there is no gas it cant do anything.  So PAC's were kind of like the old trigger that would start the SVT but it cant anymore.  Rest assured that PAC's are completely normal for many people and I think because we have had burning or freezing done to our hearts that we are more prone to them.  If just one cell in the heart is inflamed the heart can act wacky....so we may have wacky hearts :)

Don't let these things hold you back from enjoying life, and don't let it make you afraid that your SVT is back! The probability of it returning is VERY small 3-5%.  These are something we may have to live with.  It seems PAC's come in runs of a few weeks to months and then can go away on there own so I don't think they last forever.  

I hope this helps some people feel better, I am going through it too and I know its hard (believe me) but they are not life threatening and its much better then the SVT and getting adenosine etc!  Everyone stay hopeful and know that you are not alone....PAC's are extremely common and like I said benign.