vagally mediated or mechanical problem

[StephPT]

I am a 31 year old female with a structurally normal heart (EKG, ECHO, CT chest and abdomen, and all labwork have been normal) that has been having runs of SVT vs. A-fib vs. A-tach every time I eat.  It occurs with swallowing (food, and some beverages, but not with just swallowing air).  I had 18 episodes during a 24 hour holter monitor, with rates between 180-200 bpm.  These are often accompanied by lightheadededness.  I have tried multiple medications (toprol, toprol plus digoxin, verapamil, flecainide, and norpace with verapamil) with no success.  I have had two attempts at ablations (the most recent was 1/10/05) with no success.  Both times, the EP was unable to induce the arrhythmia on the cath table.  On the first attempt, Isopril was given, with no arrhythmia UNTIL it was turned off, and then I converted to atrial tachycardia, supposedly in the left atrium (he was only prepared to do a right ablation).  During the most recent study, large doses of epinephrine were administered, and with great difficulty, the EP was able to ablate some PACs on the right, but saw nothing on the left, so didn't venture over.  As a last ditch effort, yesterday, he passed an NG tube and jiggled it around (not the most pleasant experience) in an attempt to manipulate my esophagus and induce the arrhythmia, with no luck.

My doctor (in his 14 years of practice) as never seen a case like this.  He has consulted with someone at UPenn, who is also stumped.  My question is:

Could this be vagally mediated, or is it possible that structurally, my esophagus is rubbing my heart with swallowing

[StephPT]

Thanks for the info.  I have tried Protonix, even double the dose, and it has done NOTHING for my arrhythmia, although it did a great job on any heartburn I may have had!  There is very little research out there about "deglutition tachycardia" (that's the formal title for this rare condition), but most cases are in the absence of any esophageal dysfunction...I'm glad that for you, and Peter (PVC) it was that simple.

I have found an EP at TJU that specializes in autonomic nervous system dysfunction (since I am thoroughly convinced now that this is related to the vagus nerve), and I'm going to see what he has to say.  The only other options are to live with this, or go for the full boat PVI (pulmonary vein isolation) which I don't want to do.

Steph

[arthur]

Peter,

I do remember you mentioned GERD as a possible source of irritation, and of course, GERD is still considered as a controversial trigger for arrhythmias wihtin this forum.  Regardless, it's great to hear that you are doing well!!!
-Arthur

[PVC]

I am the Peter that was refered to in this discussion series.  I just happened to link into this discussion and was surprised to see the reference to my name.   So much (good) has happened over the past 4 years and I would love to share it with you or anyone else that is interested in hearing how I basically went from chronic PAC's, SVT, and LAF to 4 years of normal sinus rhythm.   The main change for me was finding out that I had significant reflux and started taking proton pump inhibitors.   I never suspected that I had the reflux until I asked for a barium swallow because of the 100% correlation between the action of swallowing and the onset of arrythmia.  I have been on the PPI's ever since and have basically remained free of the problem.  I visited the Mayo clinic, had a negative EP study and, like you, had the arrhythmia specialists say they had never heard of such a swallowing connection.  I found many articles that discussed this rare connection.
There is lots more to say but I will wait for contact before doing so.   I do not check this forum often so the best way to start up a discussion is to email me directly at ***@****
Cheers
Peter

[zvi]

Thanks for the encouragement.
I will try to get EP treatment in the near future.

Zvi

[zvi]

Thanks for the encouragement.
I think I will try EP in the near future.

Zvi

[arthur]

Going through the inner wall is a normal procedure with small risk, and it usually is needed to get to the left side of the heart where most supraventricular arrhythmias appear to originate.  The hole is made using the EP catheter through a very thin wall, which normally heals up with no problems.

-Arthur

[zvi]

Dear Steph
I am 73 Years old. I started having swallowing arrythmia in
1998. I assume it was triggered when by mistake I touched an
exposed eletrical wire and recieved a terrible shock.
After suffering some months I went to the best cardiologist
in my town ( Beer Sheva, Israel).
He first put me through EP. I was fully awake during the
procedure and didn't feel any pain! Shamefully after about
80% of the mapping, the computer failed and the process stopped. Anyway no foci was detected during the 80%.
The cardiologist told me he suspected the foci was on the other
side of the heart and in order to get there he has to make a small hole through the inner wall of the heart.
He then recommended a medicine called Rythmex in Israel which
is a trade name. The scientific name is:
propafenone hydrochloride, and like magic after 2-3 weeks
the arrhythmia stopped entirely.
I started with a dose of 150 milligrams 3 times a day.It
didn't help, so he raised it to 225mg 3 times a day and it worked!
After 2 years of taking the Rythmex the arrythmia stopped
and I stopped taking the medicine.
It returned again after about 2 years and I returned to the
Rythmex. After another year the dose was not enough and
was raised to 300mg, 3 per day.
I must tell you that until now I didn't have any side effect
from the medicine.
I hope that in the near future I will gather enough courage
to have EP even it means going through the heart inner wall.
In conclusion, I recommend you to ask your cardiologist about  propafenone hydrochloride.
Zvi

[StephPT]

Thanks for your words of encouragement.  I need to seek an opinion at a larger hospital (I have feelers at TJU and Hopkins right now), because, deep down, I think this can be induced, and therefore ablated, without the full PVI.

Living with it is definitely NOT an option, as I am way too young to deal with this for another 50 years.  My quest continues.

Steph

[arthur]

The PV isolation via an rf ablation process is a pretty straightforward and well-understood technique these days, having minimal complication rates (0-1%)at institutions with experience.  When I had mine done (for a PAF) a few years ago, the techniques were considered experimental, and in my case, a single focus was ablated to mimimize the potential for edema (the EP who worked on me had an outstanding 0% complication rate because of this minimalist approach).  

Living with a PAF-like condition with its psychological consequences and associated risk for stroke needs to be balanced with the one-time risk of a PV ablation procedure, which I am sure you have thought about.  Again, in my case, it was a no-brainer, since I plan only to live once, and the quality of that one time means everything.

-Arthur

[TITUS]

When I first started having SVT and PVCs it was always during a meal or after a meal.  I went from one cardiologist to the next.  I had an EP study that did find an abnormal pathway but was in a dangerous location to ablate.  Finally, when I started taking Aciphex, a medicine for acid reflux I improved tremendously.  When I eat salads or hard to digest foods my palpitations get worse but the aciphex helps.  I also take Sectral, the only beta blocker approved for treatment of PVCs.  They even give it to babies and you can regulate the dose.

My EP cardiologist also recommends high doses of magnesium to anyone suffering from heart arrhythmia and is watching clinical studies of flaxoil as well.

[Momto3]

I had different arrythmias that the type you are having, but I thought I might share something interesting.

When I had my second ablation for frequent pvcs, the doctors were almost certain that the foci was on the right side (EKG).   During the procedure, the pvc was mapped with a catheter using the electroanatomic Carto mapping system and mapping from the right ventricle demonstrated that earliest right ventricular activation was late in comparison to surface ECG, indicating a left-sided origin. In essence, it was a real fooler from all indications. They used calcium chloride to induce ectopics. They also told me that every time they re-started the versed (IV), the ectopic activity would come to a halt. I guess it made for a challenging procedure : )

Apparently, the versed would relax things enough that the ectopics would stop...They told me I could just stay hooked up to the meds and I wouldn't have any pvcs.  BUT, I'd be asleep all day : )

My situation may not be the same as yours, but I figured it was worth sharing my story just in case it could help.

[StephPT]

Thank you sooooo much!  I reviewed the article abstract online, and look forward to getting the entire thing in print.  I found several other, older, articles that discuss the same type of problem.  I will be taking these to my local cardiologist, and I am already exploring the options of another EP at a larger facility (possibly Hopkins).  It is so nice to know that I am not the only person who has experienced this, and that treatment is possible.

Steph

[StephPT]

Thanks for your comments.  I have no doubt that some of the medicines they give you interfere with the heart's ability to produce the dysfunction that haunts us during a normal day.  My NG tube experience is a perfect example.  If this is vagally mediated, there is NO WAY that my parasympathetic nervous system could kick in while someone is jamming a tube down my throat...I was practically clinging to the bedrails!

If the versed caused the ectopics to stop, does that mean that you were awake during the actual ablation?  I bet that was fun!

[arthur]

About 3-4 years ago, a fellow whose first name is Peter posted a similar complaint, ie, PAF upon swallowing.  He had consulted a bevy of experts, cardiologists and others, to no avail.  As I recall, the closest anyone came to an explanation was that the swallowing reflex is a complicated act involving a number of nerves ... and that somehow the signalling gets confused with an arrhythmia.

Peter has stopped posting, and I really don't know what the final outcome was.  I don't think he tried any ablations.

Having had PAF myself, I spent quite a while researching the condition and the triggers.  Assuming the PAF is a result of a focus located in the left atrium and/or the pulmonary vein ostia, it may be that the electrical activity of a nerve involved in swallowing is near enough to a focus that its activity permits the focal signalling to reach the AV node and disrupt normal rhythm.  This is a hypothesis, since it's a known fact that focal signalling is modulated by the state of the nervous system embedded in the cardiac tissue.  Two different types of signals, one acting like a gate for the other one.

The bottom line is to discover the focus or foci responsible for your PAF...and to do this you need to map that left atrium and PV ostia.  From your description, it is not clear that this was done.

BTW, an article in J. Electrocardiol. 1986 19(2), pp 193-6
describes a patient with a swallowing-induced paroxysmal SVT and the treatment that worked to cure it (surgical ablation).

Perhaps it's time to find a different EP.

-Arthur

[lmroswell]

Wow, this sounds like what my husband went through a few years back.  The doctors did not believe him when he said his heart raced when he swallowed food or drink.  But, eventually, in the ER, they were able to document an event on an EKG.  He lost 15 pounds in less than 3 weeks, because he was terrified of eating.  Eventually, the problem resolved on its own.  I do not remember what meds he was on.  An EP was recommended, but we waited it out.  I do believe that the vagus nerve was involved in some way, but no firm diagnosis was ever established.  I hope yours resolves soon.

[Momto3]

You're welcome!  I agree that some of the medicines may interfere with our "irritable" hearts.  Your experience with an NG tube sounds like something I will defintely do my best to avoid.  The whole concept of someone "jamming a tube down my throat" is um, um....NOT!!

Fortunately, the entire group who was responsible for taking care of me in the EP lab KNEW I wanted to be asleep!  They kept introducing the versed and backing off...I don't remember any of the stuff they told me about.  THANK GOD!

Good luck!  Looks like Arthur provided you with a great source of information!

[StephPT]

Also, any suggestions on how to induce the arrhythmia on the cath table, and are there any other tests I should undergo?  Thanks so much for you time!!

[Cleveland Clinic]

steph,

thanks for the post.

It is possible that the arrythmia may be induced by a disturbance in the cross talk between the innervation of the heart and digestive systems.  If it a focal arrythmia, it should be ammenable to ablation.

Clearly this isnt exactly a straight forward case and seeking a second opinion at a tertiary care center should be your next step.  

Good luck