Ectopics and Afib

Just musing here.....

For the last 30 years (I'm 57), I've had frequent ectopics pretty much every day. As in 20 to 1000 per day. But 'only' around 40 episodes of paroxysmal AF this last 19 years amounting to less than 100 hours in total.

I can get an ectopic every 4 heartbeats for an hour but no AF. I can get short runs of ectopics a few a minute for a few minutes and no AF. But, apparently when 'the stage is set', I can go into AF straight away - presumably with just one ectopic. As such, the presumption must logically be that 99.9% of the time my heart won't go into AF. But 0.1% of the time it will.

What sets the stage for AF is likely ANS-linked and/or electrolyte-linked in my opinion. (And why for me Flecainide as a sodium channel blocker has worked very well as a daily preventative and extra-boost PiP this last 10 years.)

So the question hypothetically is; what good would an ablation do? The evidence suggests that one procedure will for me as a paroxysmal AFr in otherwise good health have a 70% or slightly better chance of success (and 90% with 2 procedures), but based on the above reasoning I'm left unsure as to why and how, unless it stops every and all ectopics which I think we all know it doesn't/won't!

OR, is it that when I get AF it's TWO (or more) ectopics SIMULTANEOUSLY from different locations in the PVs (or wherever) that get the 'ball rolling' as it were?? Or is it that I have many triggers in the PVs and just one occasional one from just the 'right' place that will get the ball rolling?

Been a long day and it's late - just musing is all! Any thoughts guys??

Mike F



Edited 2 time(s). Last edit at 04/13/2018 06:58PM by mwcf.

Quote
mwcf
So the question hypothetically is; what good would an ablation do? The evidence suggests that one procedure will for me as a paroxysmal AFr in otherwise good health have a 70% or slightly better chance of success (and 90% with 2 procedures), but based on the above reasoning I'm left unsure as to why and how, unless it stops every and all ectopics which I think we all know it doesn't/won't!

Actually, we don't know that at all, and you're quoting success rates among average EPs, not highly experienced ones.

Constant ectopics have been part of my daily life since 2010. I would regularly get PACs in a bigeminal pattern that would continue non-stop for weeks at a time. Quite often the only thing that stopped them was an afib or flutter episode, and then once that was over they'd be right back. Since my ablation with Dr. Natale last August, I haven't felt a single PAC, and a Holter monitor proved I was completely free of them. I wore it for 8 days and it recorded not a single one.

So what an ablation can do for you is prevent your afib, regardless of ectopics, and quite possibly prevent your ectopics as well. Remember, ectopics aren't the problem -- making sure they can't trigger afib is the problem, and that's what a properly done ablation will do.

Hi Carey,

What I should have clarified was that the problem here in the UK is that most if not all EPs will as a first procedure - for paroxysmal AF at least - do no more than a PVI. As such, if there are any triggers at all elsewhere other than the PVs, then AF remains a distinct possibility. And that setting aside any possible PV reconnection a couple of months on.

At Bordeaux, they will definitely do the PVI and then try and initiate AF. In 60-70% of cases (paroxysmal) they won't be able to and will leave it at that. In the 30-40% of cases where after 100% sealing off the PVs they CAN still initiate AF, THEN they'll look for and ablate any other non-PV triggers. If things are even more problematic - unmappable foci etc. - THEN they'll look at other options including the line in the roof of the LA etc. although that said, the latter will likely be reserved for a touch up rather than done as a first procedure.

All of this is of course complicated by the fact that as part of a PVI quite a few ANS nerves will be ablated as part of it. In fact I read somewhere that if the right ones are inadvertently ablated then the success rate goes to 99%! I guess this is why Ernst is so interested in the ANS side of things at the moment (ganglionated plexi).

It could also be that the PVI itself REGARDLESS of its raison d'etre plays some role in making it harder for the atria to fibrillate - just conjecture on my part, but this is hardly an exact science as things stand.

It would appear from everything I've read that a PVI alone does work for the majority of paroxysmal cases. That said, I'd be a lot happier with the Bordeaux approach to as part of a first procedure going that little bit further in looking for non-PV triggers, although even this doesn't address the main reason for re-dos which is PV reconnection. And this is where Natale seems to be particularly 'on it' with the gliding catheter approach.

The only way to make sure that ectopics (and they usually do remain in the majority of cases) DO NOT trigger AF is to create linear lesions in the atria which is doubtless what happened in your (latest) procedure. That said, again operator experience is king as improperly created lines can result in other harder to treat atrial tachycardias showing up.

Regards,

Mike F

You're assuming your ectopics all exist outside the PVs but you don't really have any way of knowing that. It's entirely possible a PVI would isolate all of them (which could be just one location).

Quote
Carey
You're assuming your ectopics all exist outside the PVs but you don't really have any way of knowing that. It's entirely possible a PVI would isolate all of them (which could be just one location).

No, I'm assuming that after 19 years of paroxysmal AF it's possible that one or more ectopics do exist elsewhere than in the PVs. Believe me, I hope they don't!

Sure, it's possible, but that still doesn't doom a standard PVI to failure. The result might be you end up with the ectopics continuing in the form of PACs but no longer being able to sustain afib.

Quote
Carey
Sure, it's possible, but that still doesn't doom a standard PVI to failure. The result might be you end up with the ectopics continuing in the form of PACs but no longer being able to sustain afib.

What does that mean? Ectopics continuing in the form of PACS?

How can you tell the difference between PACS, ectopics and palpitations?

Quote
Catherine
What does that mean? Ectopics continuing in the form of PACS?

How can you tell the difference between PACS, ectopics and palpitations?

There aren't any differences, actually. It's mostly just semantics.

Imagine one little cell somewhere in your left or right atrium that has a bad habit of firing all on its own rather than in concert with the rest of the heart. When that one cell fires out of sync, that can propagate to the rest of the heart and cause an extra beat. That's a pre-atrial complex, or PAC for short (some people say pre-atrial contraction, and many EPs know them as APCs rather than PACs).

When a PAC occurs, you're likely to feel it as an extra beat, or a missed beat, or perhaps just a particularly strong beat. That feeling is known as a palpitation. A palpitation is simply the sensation of abnormal heart beats. So palpitations are what you feel when you have PACs, or afib, or PVCs, or any other sort of abnormal beats that you can feel.

Sometimes a PAC can cascade, cause more cells to fire, and initiate an episode of afib. That's what Mike is worried about. He's concerned that he has those ectopic sources outside the area of the pulmonary veins and so a standard PV isolation procedure won't prevent them from causing afib. He may or may not be right and there's no way to know until an EP gets in there and maps his atria.

Thanks, Carey. Finally. Why couldn’t Google explain it to me the way you did.

Mike,

Are you sure all your ectopics are PAC's and not PVC's? Don't know how you'd tell without a Holter (which you may have had).

On the first Holter I had, the day after my first episode, I was averaging 2 PAC's and 24 PVC's per hour (the only other one I had was when I was in afib). On my old Polar beat to beat recording heart rate monitor, I could tell them apart as the monitor did not "see" PVC's so they looked like a beat that took twice as long whilst the PAC's were short duration beats.

In my case, i always assumed that they would have a common root cause - in my case electrolyte imbalance, however the PVC's would not trigger afib.

George

Hi George,

Past Holters have shown 98% PACs with the odd PVC.

In overall terms I’d assess ablation as follows.

1. Recent onset paroxysmal - PVI more than likely enough, with touch up needed in event of PV reconnection.

2. Longstanding paroxysmal - PVI hopefully still enough but more chance than 1 above of trigger outside the PVs.

3. Persistent - PVI almost certainly not enough with likelihood that line to roof of left atria required along with other additional ablation to SVC, LoM, GP or even LAA.

I’m in 2 above (19 years, although that said still less than 100 hrs AF in total) hence why I’m not overly confident of success by PVI only. But Ernst in U.K. for example very much of mindset ‘only do what is only most likely required’ as can always come back and do more later - she is very wary of causing unnecessary damage to atria by risking doing more than is actually required.

Mike

I am 7 months out from my Natale ablation and recently given the all clear after ziopatch. I feel my PVC's still, zio results showed ectopic less than 1%. Let's hope they go to zero, but I suspect they may not and I don't care, it's not afib and I am off all drugs and feeling great for the 1st time in four years.