Junctional escape rhythm

[heartofgld]

Back in Sept I was in the ER in Afib with rapid ventricular response. IV meds failed to convert and I had to be cardioverted. In Oct I went through an EP study and had a flutter line ablation and failed attempt to ablate for AVNRT. I took Flecainaide for about 2 weeks and could not tolerate the side effects. Last month I had another ablation procedure and my EP felt that it was successful. 2 days later I was back in the ER with tachycardia(rate was 130 with 2:1 conduction) I have just not felt well since the procedure. I am extremely tired all the time, I feel my heart racing at times with the usual pac's and pvc's which I've had forever and have leared to live with. I am not a candidate for betablockers due to being an asthmatic.

At my last appt I expressed my concerns about how I was feeling. My EP said that the EKG showed junctional escape rhythm. He looked back in my history and said that this had shown up in previous EKG's. I have never experienced symptoms from it and actually would not have known this was going on unless I was told. I now am symptomatic during the rhythm. When it starts I feel like the wind has been taken from my lungs, I get lightheaded and dizzy. I was taking 360mg Diltiazem qday, now I am taking 120mg TID. I have not noticed any change in how I feel. I was sent for a nuclear stress tolerance test the other day and do not know the results of that yet.

Would my feelings of lightheadedness and dizziness be from a drop in heart rate?
At what point is this problem treated?
How is this treated?
Thanks for any info that you can offer.

[Lyn2]

Yes, that makes sense.  I have heard of a dual av node pathway.  I only had one.

[wmac]

Sorry meant to say if you DONT HAVE a dual av nodal pathway youll most like end up with a pacemaker.
wmac

[wmac]

Yes I had a av node ablation. My first ep study they said that I showed evidence for dual av node. Which keep in mind my ablation was for nonsustained vtach. Went for my second ablation 8 months later for nonsustained vtach again couldnt induce it but they did get some junctional extra beats which were consistant with the dual av nodal pathway. So they did 11 burns to the slow path way is what the report said but I think they meant to say fast pathway. I dont think most people have a dual av nodal pathway as I was consistant with but he was confident to burning it. But unfortantaly it did not fix my nsvtach problem. We talked about him burning the extra av nodal pathway and I was very concerned about having a pacemaker my ep doc said that that could happen but usually less than 1%. Maybe that is with people with dual av nodal pathway. With that said if you did have a dual av nodal pathway and they burn your av node yes youll need a pacemaker, because your av node is the pacer for the heart.
wmac

[heartofgld]

Were they able to get ablate the inapp. sinus tach? I have been to hell and back since Sept. Everytime I have come out from a procedure I have had high hopes that I would feel better, and each time I feel a little worse.

Before all of this I too, led a very active life. I have 2 children ages 9&17, I work full time as an RN and I also taught figure skating 3 eves dueing the week. Now, I have all I can do to make it out of bed in the morning. I am sick of feeling like **** and just want this saga to end once and for all! Thanks for your input.

[Lyn2]

The pacemaker will definately take care of the junctional escape rhythm.  It just won't take care of the SVT.  If they combine pacemaker placement and an ablation of the SVT, that would take care of both fast and slow.
wmac,
Are you sure you had an av node ablation?  That is almost always combined with pacemaker insertion.  Maybe it was near the av node?

[KAD]

I had to have a pacemaker placed for a junctional escape rhythm after my third ablation for inappropriate sinus tachycardia.  They were ablating in the sinus node region.  I had heart rates in the 30's and 40's and they would not increase with exercise, so they put in a pacemaker.  I felt so bad when I was in the junctional escape rhythm.  I don't know how you've delt with it thus far?  It sounds like you are very symptomatic and would probably benefit somewhat from a pacemaker.  It did help me dramatically.  I'm 29 and very active, so they chose a pacemaker that senses my activity, such as running, and speeds my heart rate up accordingly.  Take care and I hope you get some relief from your symptoms and get well soon!

[heartofgld]

I did not have the AV node ablated. When I had the EP Study and flutter line ablation the EP felt that the SVT was left sided. During my 2nd ablation he made one more attempt on the right side before doing the transeptal procedure. He was able to ablate the SVT in the right atrium but said that it was very close to the AV node.

I also get concerned about the recurrance of afib. Did you have afib before the pacemaker placement? Also, did your cardio mention doing a PVI to get rid of your abib?

Thanks for all the info. It certainly helps to hear about other's who have had similar problems.

[heartofgld]

Thanks for your advice. I am a 37 year old female. I was diagnosed with SVT about 8 years ago and up until this past Sept had minimal episodes that didn't require a trip to the ER. The cardiologist that I had was not what you'd say aggressive in trying to treat me or even find out what type of SVT I had. He was certainly singing a different tune 3 months ago when I did end up in the ER in full blown AFIb with a heart rate that reached 450 bpm! Fortunately, during my hospital stay the director of the EP lab got involved with my case. He is determined to get me back on track and has been a god send to me!
Currently, I get very lightheaded and dizzy when I go from NSR to junctional escape. It's to the point that when I'm driving I have to pull over fearing that I may pass out. As for the Flecainide, I was taking 150mg/day. I will never go on that again. He had wanted to try Propafenone, but due to my asthma, he did not want to exacerbate the situation. Have either of you been on Digoxin? Also, did the pacemaker fix your junctional rhythm?  I'm just sick of medication and had hoped that after my ablation I'd be pill free.

I'm trying to keep faith and remain hopeful but it just feels like there is no end in sight for me...one problem gets fixed and then a new one arises.

Thanks for your posts

[wmac]

I had an ablation on my av node in Sept of 05 mine turned out ok as far as your problem goes but they didnt fix my nsvt. With that being said I do know that ablating the av node is very tricky and sometime if they burn the wrong one most people will end up with a pace maker. My cardio told me of that but he was pretty good and had alot of confindence he said with that happening is like less than 1%. But maybe your heart rate is too slow and that would be consistent of that. I had a customer that that happened too and she ended up with a pace maker too. I hope things are ok and get better for you. Good luck
wmac

[Lyn2]

I have had a similar problem.  I am curious about your age, not to be rude.  When I was in my mid twenties, I developed arrythmia that required ablation.  I then went into a ventricular escape rhythm that would cause my rate to drop into the single digits.  After several fainting episodes I had a halter monitor on.  They called my house within 2 hrs. of handing in the monitor and said they were calling an ambulance.  
Subsequently, I got a pacemaker.  Since the pacemaker I have had a-fib with abberancy with a rate going over 300bpm, despite the pacemaker (it doesn't control fast rates).  Eventually, I had an av node ablation.  This is supposed to keep you from feeling those high rates.  I still have a-fib, but it doesn't go so high.  It is a dramatic step to take, but I was on every anti-arrythmic listed.  I am also asthmatic, so I became restricted from beta blockers.  I was on 480mg. of cardizem and ? the dose of flecanaide.  I have now had to go back on the flecanaide, due to symptoms.
Good luck!  There is no easy answer for this problem! Feel free to ask questions.  I am not a doctor, but I have a few years experience as a patient.

[CCF-M.D.-MJM]

Hello heartofgld,

Would my feelings of lightheadedness and dizziness be from a drop in heart rate?

Yes you could feel this.  This is related to the drop in heart rate and the fact that your atrium is not pumping blood into your heart before it contracts.  You heart is not as efficient in a junctional rhythm.

At what point is this problem treated?

The treatment is probably a pacemaker if you are very symptomatic.   This would be a judgement call based on how you feel and there is no guarentee that you will feel better after a pacemaker.  Junctional rhythm can be a complicated problem to treat.  The first step is to decrease your diltiazem or an other AV nodal medications like beta blockers or digoxin.  If it doesn't improve after stopping the medications or if you cannot stop the medications because your heart rate is out of control, this makes a pacemaker a decent option.  The goal is to only place a pacemaker if you absolately need one.

I hope this answers your questions.  Good luck and thanks for posting.