Cardiac Ablation for Intermittent Arrhythmia

3mm · Oct 11, 2024

How does an electrophysiologist planning a cardiac ablation approach an arrhythmia that is intermittent?

Some arrhythmias are intermittent, but still serious enough to consider surgery. Many days I have 20%, perhaps even 30%, PVC loading (premature ventricular contractions) for several hours or more. (Note: 20% PVC loading means that 20% of my heartbeats are PVCs) So my electrophysiologist recommends intervention because over time these PVCs are damaging my heart. I accept this is a good idea, since I want to keep my heart healthy.

However, some days I only an occasional PVC, or even have 0 PVCs. Other days I have 0 PVCs in the morning, but after exercising I have PVCs for several hours. So I'm not sure if the surgical team will see the problem while I'm on the table. All my engineering experience tells me it is very hard to fix a problem you cannot recreate.

When an arrhythmia is intermittent, how does the electrophysiologist know what to ablate during surgery? I have seen a reference to using a drug to force the heart into arrhythmia; but how would the surgeon know if the arrhythmia they forced the heart into is the patient's real problem?

I'm not finding much information about this aspect of cardiac ablations. I have emailed questions to my electrophysiologist, but I've not yet heard from their office. I will appreciate any references to medical reports, personal experience, etc. I want to get some background so I can have a useful conversation with my electrophysiologist. Thank you!

Timmay · Oct 12, 2024

Hi 3mm,

Out of my own personal curiosity, how did they quantify your PVC loading? Did you wear a monitor for a week or so? I too have Exercise Induced PVCs (aka EI-PVC). Metoprolol seems to help significantly with mine. Are you on Metoprolol at all?

Thanks.

3mm · Oct 12, 2024

Timmay said:
how did they quantify your PVC loading? Did you wear a monitor for a week or so? I too have Exercise Induced PVCs (aka EI-PVC). Metoprolol seems to help significantly with mine. Are you on Metoprolol at all?

I've worn a Holter monitor for 3 tests, twice for 2 week tests, and once for a 1 week test.

I take metoprolol. During 2 tests I was taking metoprolol tartrate, 12.5mg twice daily. During the other test I took metoprolol succinate, 25mg daily. I do not see any relation between PVCs and the time I took my metoprolol when I look at the data from my tests.

Timmay · Oct 12, 2024

Thanks 3mm. Appreciate your experience.

Woodcutter · Oct 12, 2024

3mm said:
How does an electrophysiologist planning a cardiac ablation approach an arrhythmia that is intermittent?

My understanding is they attempt to induce them (I've had a couple of ablations but my issues were not intermittent):

Sympathomimetic agents (isoproterenol or epinephrine), methylated xanthines (aminophylline or caffeine), or awakening the patient on the table may provoke PVCs. Rapid atrial or ventricular pacing causes an increase in triggered PVCs. In some instances, high-frequency electrical stimulation (50 ms train) in the proximal main or left pulmonary artery can induce outflow tract PVCs.41,42 On the other hand, atrial or ventricular extrastimulation may provoke reentrant PVCs.

Alternatively, with a multielectrode catheter, multiple points can be acquired in a single beat when the PVC is very infrequent

The above are a couple sentences from this article. It's got a nice reference list for digging even deeper

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4547666/

dornole · Oct 15, 2024

Interesting, never really thought about that. I have paroxysmal afib and they will probably do a Maze procedure tomorrow during my mitral valve replacement. I got the impression that for afib they kind of know where the chaotic impulses are coming from, near the pulmonary artery I believe. Maybe it is different for PVCs.

For me I estimate the afib burden by telling them how many episodes and how many hours they lasted. It's extremely apparent to me when they are happening and I verify with a Kardia.

I also have an older Apple Watch - it doesn't do the mini EKGs on demand, but it does do a passive heart rate variability measurement (HRV) throughout the day. I've noticed that the HRV spikes strongly on afib days (e.g. 150 ms vs a normal of about 30 ms for me) and the height of the spike roughly correlates to the number of hours in afib. Very strong match in this data to my perceptions of afib as well as what the Kardia says.

I've never had an afib episode when wearing a Holter (naturally). Only official time they documented it was in the ER before cardioversion. Which lasted 4 days before the next episode.

Curious to see what you find out.

pellicle · Oct 15, 2024

3mm said:
12.5mg twice daily. During the other test I took metoprolol

Both very low doses, personally I'd prefer trying a higher dose before starting ablations.

Eva · Oct 19, 2024

I wonder if the events recorded on the Holter monitor can be used as a guide!

Two years ago my AFib was treated with Cardioversion. Before we settled on Cardioversion, my electrophysiologist recommended EP study. The printout he gave to me states that during the EP Study, “once the catheter reaches the heart, the electrodes at its tip gather data and a variety of electrical measurements are made. These data pinpoint the location of the faulty electrical site”.

The info he printed out to me was from Heart Rythm Society. I hope you can find answers there.

https://www.heartrhythmjournal.com/...earch&text1=Cardiac+ablation+&field1=AllField

I’m seeing a new electrophysiologist next month since I had AFlutter last August. Not sure what the outcome will be.
Keep us posted and good luck.

vitdoc · Oct 20, 2024

I am not an electrophysiologist but I have had three ablations for A fib. Monitors are essentially small EKG machines which show rhythm but do not reveal the source or location of where the abnormal rhythm is coming from. Electrophysiological mapping is how the location is determined. The physician has various methods of trying to induce the abnormal rhythm if it is not present during the procedure. The pattern in which different abnormal rhythms are treated varies depending on the situation. At least for A fib the general rule is to treat it before it becomes more chronic. Results tend to be better. For some rhythm disturbances the results can be very good and long lasting for others less so. An isolated supraventricular tachycardia can often be treated very successfully. A fib varies. My treatment lasted a year or two each time but ultimately failed and I decided not to continue due to the lesser rate of success with multiple procedures.

3mm · Oct 22, 2024

I appreciate pellicle's plan for what he would do if he were in this situation. This hint encourages me to consider my options which improves my communication with my medical team. Thank you!

Below I will describe my plan and my reasoning since this information may be helpful to others who are having problematic PVCs. As always, if someone has relevant information, questions, etc., please share!

My electrophysiologist knows my Metoprolol dose, but he did not suggest increasing it. At that time I did not know that some people use metoprolol for PVCs, so I did not ask about increasing my Metoprolol dose. I will ask about that, but my blood pressure and pulse are sometimes low, so I worry about increasing my Metoprolol dose.

My electrophysiologist and medical standards say my PVC loading of 20% can eventually damage my heart, so my electrophysiologist recommends intervention, even though I usually have no major noticeable symptoms.

He did offer Sotalol as a possible drug solution, but it has some issues. When trying Sotalol a patient must be in the hospital for several days because some patients go into cardiac arrest. That scares me! I also read that Sotalol users must have periodic blood tests because of possible kidney damage. Sotalol also has all the usual beta blocker side effects: low heart rate, shortness of breath, weakness, palpitation, etc. It doesn't sound like a good long-term solution. See: Sotalol Side Effects: Common, Severe, Long Term (drugs.com)
https://www.drugs.com/sfx/sotalol-side-effects.html#refs

Hence, I decided to schedule ablation. I have 3 notable patterns to my PVCs. The main pattern is 80% of my PVCs, so the electrophysiologist will focus on it. The current plan is to ignore the 2 minor PVC patterns. We want to avoid killing too many heart cells! I do not always have PVCs, but I usually have them after exercising. I will suggest to the medical team that I exercise the morning of surgery to improve the odds that I have naturally occurring PVCs when we start surgery. If I am not having PVCs, they will inject me with some drugs to cause PVCs. I have also read that the shape of my PVCs on the EKG gives a clue about the source location in the heart muscle.

Woodcutter said:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4547666/

Woodcutter - Thank you! This article answered many of my questions and is consistent with what a cardiac nurse told me this week.

I will get a catheter on each side of my groin. I think 1 is the sensor that Eva refers to in a post above (Thank you, Eva!) The other catheter is the flamethrower. Not really, I'm just checking which thread readers are still awake. It will be a radiofrequency tool to generate heat. Because I have a mechanical ON-X aortic valve, they must go in through the other side of the heart and then pass the catheters through the wall between 2 chambers of my heart (transseptal puncture, or TSP). My electrophysiologist does several hundred cardiac ablations each year, so I am very confident in him. His nurse gave me the following statistics:
"3-5% risk of minor complications (typically that is localized bleeding that requires a few extra minutes of holding pressure on the site). 1% risk of moderate complication (typically blood in the sac around the heart causing low blood pressure and a pericardial drain would need to be placed). 1/1000 risk of major complications including heart attack, stroke, or death."

Additional general information on treatment of PVCs:
https://heart.arizona.edu/heart-hea...ders/clinical-approach-patients-frequent-pvcs

pellicle · Oct 22, 2024

Morning

3mm said:
This hint encourages me to consider my options which improves my communication with my medical team. Thank you!

welcome.

To me any ablation equals irreversible damage to tissue (and scarring). I'm a conservative guy (note: etymological origins of conservation) and so I prefer to try something which isn't irreversible first. Medications can be discontinued and seldom have irreversible consequences.

I know a few people who aren't amenable to medications and have gone down the ablation path (more resembling a Mobius strip in some cases), some aren't here anymore and one is under 30 ... just because its out of sight does not mean the scarring is not there.

I hope that you can avoid the ablation path for a little while at least.

For reference your present dose is tiddly

https://www.goodrx.com/metoprolol/dosage

For high blood pressure, the typical metoprolol dosage is between 100 mg to 450 mg total per day. Doses may be taken once or twice a day. Your healthcare provider will usually have you start at 100 mg and raise the dose weekly as needed.

myself I take 25mg AM and PM (so 50mg daily) and because I take "tartrate form" I can time exercise in with effect.

For instance, was doing some work this morning cutting up the trunk of this tree (which I downed yesterday) and took my metoprolol at about 8am.

so that by the time I'd be finished it would bring my HR down from 110 ~ 120 to more like 80 ... just finished coffee and apple turnover half an hour ago.

Yesterday late afternoon I was having some PVC's (amid the higher HR) so I took my evening metoprolol early ... they settled down by 6pm

Best Wishes

carolinemc · Oct 23, 2024

3mm said:
I appreciate pellicle's plan for what he would do if he were in this situation. This hint encourages me to consider my options which improves my communication with my medical team. Thank you!

Below I will describe my plan and my reasoning since this information may be helpful to others who are having problematic PVCs. As always, if someone has relevant information, questions, etc., please share!

My electrophysiologist knows my Metoprolol dose, but he did not suggest increasing it. At that time I did not know that some people use metoprolol for PVCs, so I did not ask about increasing my Metoprolol dose. I will ask about that, but my blood pressure and pulse are sometimes low, so I worry about increasing my Metoprolol dose.

My electrophysiologist and medical standards say my PVC loading of 20% can eventually damage my heart, so my electrophysiologist recommends intervention, even though I usually have no major noticeable symptoms.

He did offer Sotalol as a possible drug solution, but it has some issues. When trying Sotalol a patient must be in the hospital for several days because some patients go into cardiac arrest. That scares me! I also read that Sotalol users must have periodic blood tests because of possible kidney damage. Sotalol also has all the usual beta blocker side effects: low heart rate, shortness of breath, weakness, palpitation, etc. It doesn't sound like a good long-term solution. See: Sotalol Side Effects: Common, Severe, Long Term (drugs.com)
https://www.drugs.com/sfx/sotalol-side-effects.html#refs

Hence, I decided to schedule ablation. I have 3 notable patterns to my PVCs. The main pattern is 80% of my PVCs, so the electrophysiologist will focus on it. The current plan is to ignore the 2 minor PVC patterns. We want to avoid killing too many heart cells! I do not always have PVCs, but I usually have them after exercising. I will suggest to the medical team that I exercise the morning of surgery to improve the odds that I have naturally occurring PVCs when we start surgery. If I am not having PVCs, they will inject me with some drugs to cause PVCs. I have also read that the shape of my PVCs on the EKG gives a clue about the source location in the heart muscle.

Woodcutter - Thank you! This article answered many of my questions and is consistent with what a cardiac nurse told me this week.

I will get a catheter on each side of my groin. I think 1 is the sensor that Eva refers to in a post above (Thank you, Eva!) The other catheter is the flamethrower. Not really, I'm just checking which thread readers are still awake. It will be a radiofrequency tool to generate heat. Because I have a mechanical ON-X aortic valve, they must go in through the other side of the heart and then pass the catheters through the wall between 2 chambers of my heart (transseptal puncture, or TSP). My electrophysiologist does several hundred cardiac ablations each year, so I am very confident in him. His nurse gave me the following statistics:
"3-5% risk of minor complications (typically that is localized bleeding that requires a few extra minutes of holding pressure on the site). 1% risk of moderate complication (typically blood in the sac around the heart causing low blood pressure and a pericardial drain would need to be placed). 1/1000 risk of major complications including heart attack, stroke, or death."

Additional general information on treatment of PVCs:
https://heart.arizona.edu/heart-hea...ders/clinical-approach-patients-frequent-pvcs

carolinemc · Oct 23, 2024

3mm said:
I appreciate pellicle's plan for what he would do if he were in this situation. This hint encourages me to consider my options which improves my communication with my medical team. Thank you!

Below I will describe my plan and my reasoning since this information may be helpful to others who are having problematic PVCs. As always, if someone has relevant information, questions, etc., please share!

My electrophysiologist knows my Metoprolol dose, but he did not suggest increasing it. At that time I did not know that some people use metoprolol for PVCs, so I did not ask about increasing my Metoprolol dose. I will ask about that, but my blood pressure and pulse are sometimes low, so I worry about increasing my Metoprolol dose.

My electrophysiologist and medical standards say my PVC loading of 20% can eventually damage my heart, so my electrophysiologist recommends intervention, even though I usually have no major noticeable symptoms.

He did offer Sotalol as a possible drug solution, but it has some issues. When trying Sotalol a patient must be in the hospital for several days because some patients go into cardiac arrest. That scares me! I also read that Sotalol users must have periodic blood tests because of possible kidney damage. Sotalol also has all the usual beta blocker side effects: low heart rate, shortness of breath, weakness, palpitation, etc. It doesn't sound like a good long-term solution. See: Sotalol Side Effects: Common, Severe, Long Term (drugs.com)
https://www.drugs.com/sfx/sotalol-side-effects.html#refs

Hence, I decided to schedule ablation. I have 3 notable patterns to my PVCs. The main pattern is 80% of my PVCs, so the electrophysiologist will focus on it. The current plan is to ignore the 2 minor PVC patterns. We want to avoid killing too many heart cells! I do not always have PVCs, but I usually have them after exercising. I will suggest to the medical team that I exercise the morning of surgery to improve the odds that I have naturally occurring PVCs when we start surgery. If I am not having PVCs, they will inject me with some drugs to cause PVCs. I have also read that the shape of my PVCs on the EKG gives a clue about the source location in the heart muscle.

Woodcutter - Thank you! This article answered many of my questions and is consistent with what a cardiac nurse told me this week.

I will get a catheter on each side of my groin. I think 1 is the sensor that Eva refers to in a post above (Thank you, Eva!) The other catheter is the flamethrower. Not really, I'm just checking which thread readers are still awake. It will be a radiofrequency tool to generate heat. Because I have a mechanical ON-X aortic valve, they must go in through the other side of the heart and then pass the catheters through the wall between 2 chambers of my heart (transseptal puncture, or TSP). My electrophysiologist does several hundred cardiac ablations each year, so I am very confident in him. His nurse gave me the following statistics:
"3-5% risk of minor complications (typically that is localized bleeding that requires a few extra minutes of holding pressure on the site). 1% risk of moderate complication (typically blood in the sac around the heart causing low blood pressure and a pericardial drain would need to be placed). 1/1000 risk of major complications including heart attack, stroke, or death."

Additional general information on treatment of PVCs:
https://heart.arizona.edu/heart-hea...ders/clinical-approach-patients-frequent-pvcs

Catherization, they will numb the groin and then insert the senor up to the heart and valves. They will talk you through on what they see. I am not sure with two what they might see. I had one to make sure there were now clogged arteries. When they said they were fine, we all cheered. For you see, they give you a relaxer in a shot and helps keep you calm during the catherization. And good luck on the alabation.

Eva · Oct 23, 2024

@3mm , you’re welcome.

Last August, I was hospitalized (hospital x) for Atrial Flutter, which I believe was triggered by the stress of stopping warfarin, taking Lovenox, and undergoing a breast biopsy. During my stay, numerous doctor/residents suggested and pushed that I undergo ablation. To keep this brief, I agreed to see an electrophysiologist after a cardioversion once I was home.

Two weeks ago, I had partial mastectomies on both sides. Naturally, I was very stressed before and after the procedure. I started feeling higher pulse on and off.

This past Monday morning, I woke up with a high pulse of 110. I doubled my Metoprolol dosage (100 mg instead of 50 mg) in the morning and evening.
Yesterday, Tuesday, I saw one of my two cardiologists, who had treated me during a similar episode in February while I was in the hospital (hospital y) and refused cardioversion. I was then put on a Cardizem drip and Toprol which worked perfectly.

Yesterday, the cardiologist recommended I go to hospital x emergency. I refused since I had no other symptoms. I reminded him of his February treatment with Cardizem and “almost begged him” to prescribe it until I see the new electrophysiologist next week. He reluctantly agreed after I promised to go to the emergency room if I felt worse. Started Cardizem yesterday in addition to my metoprolol. With both medications, my pulse is starting to decrease. What a relief!

I am still scheduled to see the electrophysiologist next week. My point is, if your PVCs are triggered only by exercise, perhaps your cardiologist or electrophysiologist can prescribe a medication you can take before exercise that might help. In my case, I am still against ablation, as I have read that it is not always successful. My question for my electrophysiologist is whether I can take Cardizem in addition to Metoprolol if this happens again and again until it stops working!. My previous electrophysiologist mentioned that ablation (though doable) is a very tricky procedure in my situation.

Good luck and keep us posted.

dornole · Oct 24, 2024

Going through some of this myself. I just had a Maze procedure ablation as part of my open heart surgery, hopefully to prevent the return of afib or it becoming permanent. So far so good, but now a few days post op while still in hospital developed atrial tach. The first EP guy who came around was thinking amiarodine (talk about a tricky drug!). After they conferred together they went with a high dose of metoprolol instead and it seems to be bringing the HR down. They also have another option since they just put a pacemaker in me yesterday (for complete heart block). It basically has a sub program they can run at the click of a button to try to get the heart back in rhythm. It didn’t work today but it might tomorrow esp with the metoprolol helping. Plan B latest I heard was sotalol - didn’t think it would require more days of hospital! I would like plan A. It’s nice that the pacer program could be repeatable if it works. Just go to clinic and they can run it.

Good luck with it all!

3mm · Oct 24, 2024

Dornole - I pray your heart stabilizes!

dornole said:
pacemaker in me yesterday (for complete heart block). It basically has a sub program they can run at the click of a button

Where is the button? How does it communicate with the pacemaker? Is the pacemaker implanted under your skin?

dornole said:
Plan B latest I heard was sotalol - didn’t think it would require more days of hospital!

I have read that Sotalol users need regular kidney function checks via bloodwork. However, I don't know the probability of a Sotalol user developing a kidney problem.

3mm · Oct 24, 2024

pellicle said:
Your healthcare provider will usually have you start at 100 mg and raise the dose weekly as needed.

This morning my family doctor's nurse measured my blood pressure at 98/40, and my pulse at 38. Hence my family doctor thinks increasing my Metoprolol would risk dangerously low blood pressure and pulse. I will also ask my electrophysiologist about this.

pellicle · Oct 25, 2024

3mm said:
Hence my family doctor thinks increasing my Metoprolol would risk dangerously low blood pressure and pulse. I will also ask my electrophysiologist about this.

agreed, that's bradycardia ... had you mentioned that before and I missed that.

Sorry

dornole · Oct 25, 2024

3mm said:
Dornole - I pray your heart stabilizes!

Where is the button? How does it communicate with the pacemaker? Is the pacemaker implanted under your skin?

I have read that Sotalol users need regular kidney function checks via bloodwork. However, I don't know the probability of a Sotalol user developing a kidney problem.

Thanks for the kind prayers 3mm. “Button” is a little tongue in cheek. In order to shift the routine on the pacemaker from the regular heart block program to this other program they just need to program the change and lay the provider’s pacemaker management device on top of my pacemaker and they will pair up and make the change. The point is that it is super easy to try.

dornole · Oct 25, 2024

dornole said:
Thanks for the kind prayers 3mm. “Button” is a little tongue in cheek. In order to shift the routine on the pacemaker from the regular heart block program to this other program they just need to program the change and lay the provider’s pacemaker management device on top of my pacemaker and they will pair up and make the change. The point is that it is super easy to try.

Cardiac Ablation for Intermittent Arrhythmia

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