Diminished P wave and ectopics

Here's some interesting observations that stem from another post here.....
My last visit with Natale a big debate occurred between him and one of his "in training" staff.
His doctor could see no P wave on my EKG. Before Natale came in she claimed I was in some type of abnormal rythym
He comes in and says no he sees slight P waves and that was normal for me. She could not find them. My P wave is diminished from previous ablation procedures.
Natale said no problem, she never understood.
So this month with my EP here in KY my EKG shows afib. I wasn't in afib. I had a few PACs and slight P wave. My EP said if I ever have an EKG somewhere and they tell me I'm in afib, just laugh and tell them I'm ok.
I admittedly am not as sharp on the readings as some on this site, so I don't fully understand. If anyone can shed light greatly appreciated.

And now I'm wondering....how the heck will I ever know if I'm truly in afib?? And at what point would I become concerned?

I have the same situation after my 2nd Ablation when my LAA was isolated; No P Wave. I was told by my local Cardiologist that I was in AFIB 1 year ago but Dr. Natale said not true and not in AFIB. It pissed off my Cardiologist whom Honestly I have not been back to but I rarely have any Arrhythmia problems; Just good NSR but no P wave and daily Eliquis.

No one was ever able to explain it to me. I actually never spoke to Dr. Natale but TEE was excellent except no P wave. What would my Chad score be? P Waves are not normally figured in when determining Chad Score.

Anyway, Would love to hear a layman’s explanation myself.

Very interesting! Well I guess there's two of us!

Is the left atria contracting/pumping normal when there is only a diminished P wave?

I’ll throw out a guess and say that those with extensive lesion sets in the left atrium, extending well beyond the normal pulmonary vein isolation to include areas such as the posterior wall and left-atrial appendage, might experience significant conduction abnormalities as charge propagates from the sino-atrial node in the right atrium across the more heavily scarred left atrium, and this abnormal conduction presents electrographically as a diminished P-wave on the surface of the skin.

How’s that for a theory (and a run-on sentence)?

Here is my TEE Report. I made a mistake. I am minus the “A” wave.

DATE OF STUDY: 12/08/2016
ORDERING PHYSICIAN: Andrea Natale, MD
PERFORMING PHYSICIAN: Hashim Khan, MD
PROCEDURES PERFORMED: Transesophageal echocardiogram with complete 2-dimensional imaging, spectral, and color flow Doppler imaging.
INDICATIONS: Paroxysmal atrial fibrillation, status post ablation. Left atrial appendage evaluation.
DESCRIPTION OF PROCEDURE: Informed consent was obtained. After this, the patient was given a total of 3 mg of intravenous Versed and 75mcg of intravenous fentanyl for conscious sedation. Once adequate sedation was obtained, the transesophageal echocardiogram probe was inserted into the oropharynx and distally into the esophagus. Systematic 2-dimensional imaging, spectral, and color flow Doppler imaging was undertaken. Once all images were carefully reviewed, the probe was removed from the patient's body and he awoke without complications.
FINDINGS: 1. Left ventricle: Wall thickness is normal. Chamber size is normal. Systolic function is normal. Ejection fraction is visually estimated to be 55-60%.

2. Right ventricle: Wall thickness is normal. Chamber size is normal. Systolic function is normal.

3. Left atrium: Normal in size. Well visualized. No mass or thrombus. Left atrial appendage is well visualized.No mass or thrombus. There is color flow in and out of the left atrial appendage. Left atrial appendage emptying velocities of 50 - 60cm/sec.

4. Right atrium: Normal in size. Well visualized. No mass or thrombus.

5. Interatrial septum: Intact without any evidence of shunt of color flow mapping.

6. Aortic valve: Trileaflet valve, which is normal in structure and function. No stenosis or regurgitation.

7. Mitral Valve: Normal structure and function. There is trace mitral regurgitation. Pulse wave Doppler analysis of mitral inflow shows E waves only. Tall E waves ore noted. No A waves are seen.

8. Tricuspid valve: Well visualized. Normal structure and function. Trace tricuspid regurgitation.

9. Pulmonic valve: Well visualized.Normal structure and function. No stenosis or regurgitation.

10. Pericardium: Intact. No pericardial effusion is noted.

11. Aorta: The ascending aorta is normal in caliber.

COMPLICATIONS: None

CONCLUSIONS: 1. Normal left ventricular systolic function.

2. Normal left atrial appendage emptying velocities.

3. There is no evidence of A waves on mitral inflow.

Continue OAC

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wolfpack
I’ll throw out a guess and say that those with extensive lesion sets in the left atrium, extending well beyond the normal pulmonary vein isolation to include areas such as the posterior wall and left-atrial appendage, might experience significant conduction abnormalities as charge propagates from the sino-atrial node in the right atrium across the more heavily scarred left atrium, and this abnormal conduction presents electrographically as a diminished P-wave on the surface of the skin.

How’s that for a theory (and a run-on sentence)?

All plausible. Just wondering if the diminished electrical signal equals diminished contraction of the left atrium?

Do you remember them doing the TEE?

From my understanding my "P" wave is diminished from my initial right atrial burns (too close to sinus node). As a result my heartbeat is originating in a weaker section of the node

Diminished P waves do indicate diminished atrial contraction. Mine are very diminished but I've never noticed any decline in cardio capacity so it's just an anomaly on paper.

If any medical professional ever diagnoses afib based solely on missing P waves, I would seriously question that person's knowledge and their ability to interpret an ECG. The hallmark of afib is an irregularly irregular heart beat. If you can't see P waves but the rhythm is regular, then it's not afib. There several reasons why P waves might not be visible or might be very low amplitude and hard to see.

What Carey says.

Can anyone explain my missing A Wave or my results above from my Tee?
Thanks

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smackman
Can anyone explain my missing A Wave or my results above from my Tee?
Thanks

Has to do with mitral stenosis. "An A wave on the mitral echogram (in sinus rhythm) excludes severe mitral stenosis; when an A wave is not seen, no definite statement concerning severity of mitral stenosis can be made." <[www.ncbi.nlm.nih.gov]

This article is about diminished P waves, don't know if it is of any help as I don't read ECGs, but I happened to see this article.

Abstract

Aims

A correct identification of the P wave is crucial for the diagnosis of narrow QRS tachycardias. This is sometimes difficult because atrial activity is hidden in the T wave. The aim of this study is to evaluate the usefulness of a T wave filtering technique based on wavelet transformation to identify atrial activity.

[academic.oup.com]



Edited 1 time(s). Last edit at 11/24/2018 08:41PM by Elizabeth.

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smackman
Can anyone explain my missing A Wave or my results above from my Tee?

Your LAA was isolated, right? That's a common finding with people who've had their LAA isolated. An E:A ratio over 2 usually indicates diastolic dysfunction as George mentioned, but if your LAA has been isolated that's kind of a false indication. It doesn't indicate diastolic dysfunction but it does mean your LAA isn't performing well enough for you to come off anticoagulants. That's kind of a shame for you because you've got excellent flow velocity in your LAA, which otherwise would have bought you a ticket off of anticoagulants. That's why the report concludes with saying you should remain on ACs.

Thanks Carey. In the presence of pac's would the ekg possibly flag afib? (With slight or no P wave)
Appreciate your knowledge
Tim

If there were a lot of PACs it might, but I wouldn't pay much attention to the diagnostics from an EKG. Doctors sure don't.

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Carey

Can anyone explain my missing A Wave or my results above from my Tee?

Your LAA was isolated, right? That's a common finding with people who've had their LAA isolated. An E:A ratio over 2 usually indicates diastolic dysfunction as George mentioned, but if your LAA has been isolated that's kind of a false indication. It doesn't indicate diastolic dysfunction but it does mean your LAA isn't performing well enough for you to come off anticoagulants. That's kind of a shame for you because you've got excellent flow velocity in your LAA, which otherwise would have bought you a ticket off of anticoagulants. That's why the report concludes with saying you should remain on ACs.

My LAA was isolated. I am taking 2.5 mg of Eliquis 2X a day instead of 5. That’s a big help as far as bruising but the Expense of the newer blood thinners is a thorn in our finances. Always getting in donut hole on Medicare Part D prescription drugs.

It's possible another TEE six months later would show improvement. I don't know how much it would cost you to do that and it's a gamble, but it might be worth the shot if it got you years of no more Eliquis. And, of course, you could always switch to warfarin, which is dirt cheap.

Quote
tsco
Here's some interesting observations that stem from another post here.....
My last visit with Natale a big debate occurred between him and one of his "in training" staff.
His doctor could see no P wave on my EKG. Before Natale came in she claimed I was in some type of abnormal rythym
He comes in and says no he sees slight P waves and that was normal for me. She could not find them. My P wave is diminished from previous ablation procedures.
Natale said no problem, she never understood.
So this month with my EP here in KY my EKG shows afib. I wasn't in afib. I had a few PACs and slight P wave. My EP said if I ever have an EKG somewhere and they tell me I'm in afib, just laugh and tell them I'm ok.
I admittedly am not as sharp on the readings as some on this site, so I don't fully understand. If anyone can shed light greatly appreciated.

And now I'm wondering....how the heck will I ever know if I'm truly in afib?? And at what point would I become concerned?

This is interesting as I have a similar situation.

Somewhat of a long story. In March 2011 had a Natale ablation for paroxysmal atrial fibrillation and have been issue free since. Last year I had a routine check-up with my regular cardiologist. Because of my age, blood pressure medication and arrhythmia history (CHADS score) recommended that I begin anticoagulant medication. I was very opposed to this due to all the potential issues with the medication. So, I contacted Natale's office for his opinion but due to the length of time since my procedure they were unable to offer any advice without being seen in person. Since it was not an emergency the appointment was several months later.

After my ablation I had wanted to establish a relationship with a local EP cardiologist here in Houston and got a recommendation from Natale (thanks to Shannon). It was much quicker to see this doctor(a couple of weeks) so scheduled an appointment with him as well. After we discussed the purpose of my appointment he examined my EKG and promptly said "you are in arrhythmia right now"!! He explained how my EKG indicated that I was in a arrhythmia. I told him II can't be.....I know what it feels like when it occurs. At this point, re-ran the EKG plus went back to my records to get previous test results......also requested a copy of the EKG from my recent appointment with my cardiologist.. After reviewing all four results he said "I'll be damned"...." it looks like you are but you are not". He explained how the P-wave was diminished......most likely the result of my ablation.

At my appointment with Natale related the conversation and after reviewing my EKG he indicated that my situation was not uncommon. Also, that it was important to be knowledgeable in the event that someone with lesser experience with atrial fibrillation interpret my EKG. I told Natale that " if arrhythmia ever rears its ugly head again I will be headed back to Austin". He laughed.

By the way......did not start the anticoagulant medication.


Steve
Spring, Tx.

Jayhawk
Same story here. He also told me anticoagulant not necessary. It's funny that even his training doctor just couldn't get it. I had an appointment just a cpl weeks ago with my EP here and he was the one that told me to ignore anyone that says I'm in afib. Lol. I wonder now tho how would I diagnose afib? I mean other than feeling it but they say as we age the sensation is less and less........ Just curious do you have many ectopics?

It drives me batty that medical professionals are diagnosing afib based on not being able to see a P wave. If the rhythm isn't irregularly irregular, then it is not afib. It really is that simple. P waves be damned.

Lol. I know. My EP said "well the ekg says you are in afib, but you're not!" So the machine labeled it such. I didn't see it but he said it was because some pacs mixed with dismal "p" waves ...lol

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tsco
Jayhawk
Same story here. He also told me anticoagulant not necessary. It's funny that even his training doctor just couldn't get it. I had an appointment just a cpl weeks ago with my EP here and he was the one that told me to ignore anyone that says I'm in afib. Lol. I wonder now tho how would I diagnose afib? I mean other than feeling it but they say as we age the sensation is less and less........ Just curious do you have many ectopics?

tsco.......

Most likely do have some ectopics. Difficult to say how frequent as they are not really noticeable. What I do notice is that I get occasional skip beats.....not even aware of how long it lasts. Otherwise basically a non-event for me.

Neither Natale or John Seger (Houston EP cardiologist) stated that I did not need to take anticoagulants.....but both said indirectly that probably not necessary.

Between the appointments with Natale and Seger.....my regular cardiologist had me do an echo cardiogram. I have been on blood pressure medication since I was 25 (hereditary condition). Per the test results my heart is in excellent condition., I played sports all my life (college baseball player) and have stayed in descent physical condition (at least until my knees became severely arthritic and I had bi-lateral replacements......whole other story!!). I retired this summer and now train three days a week at sports training facility here in Spring.


Steve
Spring, Tx.

A robustly consistent A wave as seen at the mitral valve inflow is one of the three main confirmations required on the 6 month post LAA-Isolation TEE scan for the patient to be considered eligible to possibly stop their OAC drug after an LAA-iso. They also need to pass the LAA emptying velocity measure with at least 40cm/sec flow velocity from the LAA to possibly get a pass on absolutely needing to stay on OAC drugs prior to any LAA Ckisure procedure.( Which I highly recommend, in any event, for all those with LAA ISO.

Carey is right in his description of A wave issue, as well as in his post above on P wave hysteria in Afibbers post ABL. that is the lazy mans DX of AFIZb usingbonly the relative absence of a p -wave to diagmise AFIB. Besides in post ablation the apparent absence of P wave is tyoucallnon seen in certain legs of the 12 lead while other leads show the P wwave still.

But this thread is really about the A Wave in any event. In many TEE/TTE studies the Cardio will look at both the A-wave (positive inflection above the zero or null horizontal line of a sine wave) and the E-wave when looking for certain issues or diagnosis ... such as systolic disfunctiin as Carey noted above. But with reward to LAA function ... or lack thereof ... after at 6 months LAA Isolation ... itvus only the Doppler A-Wave reading that is relevant and it must be consistently robust with every heart beat plus their has to be at least 40cm/sec LAA emptying velocity and finally the three criteria that must be met to ‘possibly’ earn a pass on needing life long OAC if you don’t go for LAA Closure, is the absence of any SEC or ‘Smoke’ seen in either the left atria or LAA. And wispy strands or smoke indicate turgid or more static blood flow which obvious is clot inducing.

Shannon