Should I go for another round of Ablation

[yeomeister]

I am a 41year old chinese male, 80kg, 1.74m, living in Singapore and in need of advice if I should go for one more try of ablation versus oral medication.

My medical conditions are vasomotor rhinitis and hypersensitivity to topical iodine.  
Notable medical history is severe hayfever in the UK for 4years treated aggressively with tefernadine. This was 18 years ago.

16years ago I was diagnosed with Right Bundle Branch Block.  

7years ago I was admitted for tachycardia and had partial ablation done.  It was partial because my reentry points were in the lateral and anterior wall, but the hospital I was admitted to only had machine to ablate the posterior wall.  The diagnosis then was Idiopathic Fascicular Ventricular Tachycardia.  After ablation, I was put on oral Verapamil.

5 years ago, I learnt I have sleep apnoea and I have since started on CPAP.

4 years ago, I underwent elective ablation when they had the required machine.  The outcome was supposed to be 90% successful, but the tachycardia returned 2 days post-op.  Instead on 1 pathway, I ended up with 3.  I was obviously disappointed, swore off ablation and opted for oral medication.

2 years ago, I woke up one morning with tachycardia again.  Was admitted.  I opted for ablation as oral medication was not as foolproof as I thought, but the outcome of the ablation was worse.  3 pathways have now given way to multiple complexes in the anterior, lateral and posterior walls and the apex.  The ablation was pretty extensive and the scars that formed after the procedure are actually visible under MRI, but the re-entry points are all over the place. My condition was then managed with Verapamil 40mg 6hourly (I could not tolerate the slow release).  

All these while, my blood vessels and muscular (EF 55%) were within the normal range.    

Unfortunately, 1 week ago, my tachycardia returned despite strict compliance to my medication and I had another emergency admission.  This time round Verapamil did not work, as did a number of emergency intravenous medication.  They had to do cardioversion on me (50J, 50J, 70J) on me the first time to regain sinus rhythm.  A few hours later the tachycardia returned even though I was on iv esmolol and another cardioversion was needed (50J, 50J, 70J, 150J).  To avoid further cardioversion, a temporary pacemaker was inserted to support their trial usage of iv amiodarone.  Amiodarone did the trick, my condition stabilised and was sent to the general ward where my Dr started me on Sotalol 80mg 2times a day as he was concerned amiodarone is too aggressive and took away the option of ablation which he is strongly recommending.

2D Echo from this admission now showed dilation in both atrium and the left ventricle.  My EF is now 30% as my heart is no longer contracting in synchronised rhythm.  Therefore, my heart function has severely deterioated.

Looking at my medical history, it should be obvious why I am conflicted between ablation and medication.  Neither has worked well in the long term.  Looking back, if I had not gone for the elective ablation, I would have been in a better shape with oral medication, but the draw of living life without medication was something I could not reject then.  I will not cry over spilled milk.  What I need to decide on, given my current heart function, is whether I should give ablation another try or stay with medication and see what comes.  I would appreciate your views, and advice where possible.

[cindy707]

Sorry that this is all happening to you...Docs only have the ability to go as far as they can with ablations and this is why i worry so much when i see posts here like yours.  I am super opinionated about finding the right doc to do the ablation.  Obviously if you have scarring which is effecting all of this they cauterized the procedure which to me is a big no no because it does using heat cause just this type of scarring thus increasing the chances of the electrical activity not re directing properly. Mostly in the U.S. they use cryo during the ablation procedure because there is virtually no scarring.  If you are in the 50% range of success with your history i would be very pro active with my body and seek a second opinion with another well known doc in your area.  The meds would have a difficult time with working with your heart now that the problem has moved into being structeral.  I sounds to me like you really really need a second opinion and that first question for me would be how many ablations have you done and if they've done under 1500 i wouldn;'t go there.  There is a toss up because a standard pacemaker and an auto fib because both will be implanted the same way an auto fib will only come into play PRN or as necessary when you throw out fast or irregular rhythms where a permanent pacemaker is an all day situation.  You need to get another opinion and even with scarring that is effecting your heart so much a good heart doc can minimize that and in many cases correct it.  Next time if you chose to do another ablation be absolutely sure that they are using cryo not heat..................

[yeomeister]

The Dr presented the choices before me:
1. Ablation
a. Chances of success if less than 50%.  The Dr who treated me has returned to USA and transferred me to my current Dr who is not sure what he will find as he was not involved in any of my past ablations.
b. Due to extensive ablations, there is a 10% chance I will get complete heart block and will need a pacemaker.  The pacemaker will protect me from lower heart rate, but will not prevent tachycardia.  I have 2 types of pacemaker to choose from: standard or integrated with auto-defib

2. Medication
a. My current medication dosage has acceptable side effect, but over time when its dosages increase or when more aggressive medication is needed, it may not be tolerable.
b. I will end up with pacemaker then.

The conudrum before me is he can't advice me on the risk-benefit ratio of either course of action as there is still insufficient evidence for my Dr to advice.  For me now, it is either risking a pacemaker now (assuming worse case outcome from ablation) or pushing pacemaker to a later date.

[ksig]

If you read the blog, many of use have had more than one or two ablations to conquer the dreaded arrhythmias... I, myself, have had four and I still have AFib although it is not nearly as intolerable as it has been in the past. What does your doctor recommend? another ablation or meds?
ksig