Holter data obtained while participating in an anaerobic sport.

I competed in an action pistol contest last weekend while wearing the Holter.

Action pistol (or practical pistol) is an international sport which combines speed, accuracy, and athletic ability. The targets are both static and dynamic (falling/swinging/disappearing/moving/bobbing/etc.). The shooting positions are equally varied (through ports at heights from the ground up to five feet high, around objects, while standing, running, kneeling, prone, often shooting around or through objects which interfere with the shooter's view of the targets, sometimes the same target can be seen from multiple positions (which can lead to shooting at it too many times, unnecessarily), etc.).

A contest consists of many "stages". Each stage is a unique combination of shooting challenges and usually can be shot in various ways. The shooter has to decide himself how to shoot the stage. You usually get about five minutes to look at the stage before you have to shoot it for score. Some stages (surprise stages) have to be shot without any prior knowledge of what is expected of the shooter.

For a skilled shooter most stages take less than 30 seconds to complete. During that time the shooter will engage about twenty five targets, have fired 40 shots, and will have covered a distance of about 20 yards, while moving between three to six or more different shooting positions, often navigating over, around, and through obstacles along the way.

The shooter is scored by taking the points determined by his accuracy and dividing by the time it took him to shoot the stage. The creates an enormous problem, in that the shooter is psyched up to go super fast, while having to be gentle and careful while shooting so he doesn't lose accuracy.

The shooter will typically fire aimed shots at a rate of about six shots per second at closer targets and about two aimed shots per second when the targets are 150 feet away. Each shot is truly an aimed shot, but at these speeds the process is more like writing your signature; you've long ago forgotten how you do it in any detail. It just happens automatically once you start. But, if you try to go just a little too fast life can get very confused real fast.

The fact that a given stage can be shot multiple ways leads to decisions along the way to change the plan depending on how the shooting is going (making up misses which require changes in when magazines need changed causing changes in the best way to shoot the stage, for instance). At the speed things are happening this can lead to massive mental confusion if your feet get even a little ahead of your brain.

There is one "standard exercise" which will give you some idea of what such shooters are capable of. Imagine three 12" round targets 30' from the shooter. The shooter starts standing with his back to the targets and with his hands touching his ears. Upon hearing a buzzer the shooter will turn to face the targets, draw his handgun from his holster, and fire two aimed shots at each of the three targets. Then he will drop that magazine, retrieve another magazine from his belt, reload the gun, and fire two more aimed rounds at each of the three targets. From the sound of the buzzer until the last shot can be less than four seconds (turning, drawing, six shots, reloading the gun, and six more shots all in under four seconds). For the best shooters the four shots in each target will typically be inside of a six inch circle.

Each shooter is also busy taping and resetting targets when the other shooters are shooting the stage, and officiating, or recording, etc., and it is usually hot in the bays where the stages are shot. So this is highly stressful, disciplined, steady, but mostly anaerobic activity. It is very tiring though, and results in flooding the system with adrenaline, even more so when shooting the stage. While shooting a stage the action is best described as a controlled explosion of precision action.

I'm classified as a master class shooter, but I earned that ranking fifteen years ago. Still, I'm no beginner at this sport. I'd gone to a few contests lately for the first time since a-fib appeared, and occasionally during the contest I thought I had popped into a-fib for short times (erratic beat strength and very irregular heart rate). The contest this last weekend involved an unusually large number of shots, and the stages were unusually challenging and complicated. I was sure I had lapsed into a-fib several times for minutes at a time, especially when I was hot and tired.

The Holter told a very different story. These numbers are for 24 hours, while the contest period was about 8 hours long each day.

The 24 hour average heart rate was 86 bpm, while my normal 24 hour average is 75 bpm. All the elevated heart rate occurred during the 8 hours of the contest, so my average heart rate during the 8 hours was elevated by about 33 bpm. That's almost all just the result of extra adrenaline. The average level of physical activity is not particularly high when you are not shooting.

Total PVC count during the 24 hours was 141, while my normal count is about 100. The extra PVCs occurred during the contest period.

Total PAC count during the 24 hours was 292, while my normal count has lately been a little higher than that.

SVT time was similarly unchanged.

Total irregular rhythm time during the 24 hours was 25 minutes. Such a number is not unknown, especially during the last six months, but usually it has been closer to 10 minutes per 24 hours lately. The irregular rhythm is not a-fib or a-flutter related. The waveforms were always normal PQRST waves, just at an irregular rate.

Participating in this sport produces a very high sustained level of adrenaline, with even more adrenaline flows while shooting (heart rate at or a little above 140 bpm for the 30 seconds). However, whatever caused the irregular heart rate was relatively unchanged from a normal day. But, the high heart rate and probably high blood pressure, and the resulting strong heart pulsing make the irregular beating very noticeable when it happens.

This data has little relevence to aerobic exercise, obviously. Perhaps the only useful information is that in highly stressed situations one can experience symptoms identical to a-fib even though a-fib is not actually present.

This then is the opposite of silent a-fib. It seems like a-fib is obviously present, but it isn't a-fib.

Wil, when you say " The irregular rhythm is not a-fib or a-flutter related. The waveforms were always normal PQRST waves, just at an irregular rate.", you have lost my nontechnological self. Do you mean that these irregularities were what we have been classing as ectopics, meaning pac's, pvc's, bi- and tri- and quadri- geminies, and svt's? Or what were they, in terms i might be more familiar with?
PeggyM

Wil, what a beautifully written story. I could visualize every single thing you were saying. I feel as though I have learned all the essentials of a sport that is totally new to me, missing only the details of preparation such as how one might practice, choosing and maintaining the gun, cartridge belt, etc. I hope there is a place within your sport where you might submit that description so that others could understand what the sport entails.

The message I take about "heart" is that when our bodies face stressful but anaerobic situations the heart may respond with abnormal beats and rhythms that do not indicate anything important for situations other than the unusual one. And if one already experiences unusual beats and rhythms when at peace, those unusual beats and rhythms may change character for a while, even mimicking serious problems. So, if we put ourselves in stressful situations and weird things happen, don't sweat it, so long as it all comes back to the usual pattern pretty quickly.

Thanks so much for sharing this experience, Wil. Kagey

"Do you mean that these irregularities were what we have been classing as ectopics, meaning pac's, pvc's, bi- and tri- and quadri- geminies, and svt's?"

None of the above. The simplest explanation is that the SA node pulsing rate has become irregular. The next most plausible explanation is that some tissue at the edge of the SA node, or located nearby, is pulsing at a rate different than the SA node and is competing with the SA node for control of the heart beat rate.

We also don't know if this kind of heart behavior is specific to ablatees.

Regardless, a noticeably irregular heart beat, which definitely feels exactly like a-fib, may not be a-fib. Only an ECG/Holter can determine whether a noticeably irregular heart rate is the result of a-fib/a-flutter.

Go to [youtube.com] and type IPSC into the search function. That will bring up Sevigny, Goloski, Leatham, etc. shooting contest stages. IPSC corresponds to International Practical Shooting Confederation.

Thanks for the explanation.
PeggyM

Wil, you may not recall but following my Natale ablation a year ago, I now have two separate sinus rhythms, one usually around 60, one usually in the high 80's or low 90's. (The faster one was a vigorous 140ish tachycardia for about 5-6 months after the ablation, and then it slowed into the 80's and developed a clear-cut P wave, and has stayed there ever since. The slower rhythm was very slow at first, 40's, and has gradually increased and apparently stabilized around 60.) Occasionally I'll have a pulse in the 70's, and I don't know what to make of that.

This outcome is consistent with your idea that two separate pacemaker areas are competing for control. The only time I am "aware" of anything going on in my heart is when there is obviously competition going on during a shift. At those times my beat will be irregular, though not with the profound irregularity I felt when I as in AF over a year ago. More like minor "palpitations." The irregularity consists of 3 or 4 slow beats shifting to a faster rhythm for a few beats, then slow again, etc. Once a new rhythm is established (usually within a few minutes), it typically stays for hours, often days. Such noticeable shifts seem to be coming more rarely as time passes. And no, at this point I don't feel the need for a personal Holter; my curiosity is, I'm afraid, not as deep as yours. I think I mentioned that Natale is very much hoping no attempts at a further ablation will be necessary, ever, because he is afraid that going after one of the two sinus rhythms would disrupt the other as well. I have no intention of challenging that line of thinking!

I asked Hans if he were aware of anyone in his experience who came out of an ablation with two sinus rhythms, and he was not. I guess I'm that experiment of one, and a total outlier at the same time. Natale said he has seen other occasional situations, but not after ablation.

Take care. Kagey

I'm surprised ablatees who have experienced transient a-fib, after months and years post-ablation, haven't chimed in on this subject. It would be interesting to know if their transient a-fib episodes were confirmed by an ECG. If not, then our fears about the return of a-fib post-ablation may be greatly exaggerated.

As I said, Natale wasn't shocked at all by the concept of dual sinus rhythms with competing pacemaker tissue. He agreed that the two pacing regions would be very close together, which is why he wouldn't want to touch them, and the rhythm irregularities while the two are "competing" seemed valid to him. I suspect you are right in thinking that any irregularity in post-ablatees is automatically assigned to flutter or AF, and then by a turn to meds, etc. Somehow I don't think it's an issue that's going to catch on, though. Most folks do not want to afford their own Holter and EKG equipment, and of course cardiologists are not likely to put them out on extended loan. Should I ever get to the point where the two become troublesome - like suggesting ablation - I'd opt for your self-analysis path to make sure just what was going on.
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I'm not a firearms user of any sort, but I found myself actually experiencing the stress of performance as you described the combined time and accuracy pressures - it was indeed a great description.

KG

I have noted that my irregular rhythm periods terminate abruptly with a return to a very steady and stable NSR.

We may share a somewhat similar SA node situation. The difference is that in your case control moves abruptly from one pacemaker to the other, for a period of time, before control abruptly returns to the original pacemaker. In my case the two pacemakers fight for control, for a period of time, until the alternate pacemaker goes dormant and the SA node alone controls the heart again. Another difference is that my irregular rhythm periods never exceed several minutes (at a contest) and usually terminate in less than 10 seconds (in normal life).

My question above is still of interest; I wonder if this is one of the possible consequences of an ablation, or is it just another consequence of heart deterioration. The fact that both of us see it gradually changing with time post-ablation suggests it is ablation related.

Wil, are you real sure that this condition developed after your ablation, and was not present before that? Just curious.
PeggyM

I remember telling Minerva, the morning after the first ablation, that my heart was alternating between two rates. The transitions between rates were occurring randomly, but typically about every few minutes. When I reported the heart rate transitions to her she told me such an bi-stable rate was impossible, but as we talked she saw it on the monitor too, and she seemed puzzled by it. Judging from her reaction, I'd have to assume that she hadn't seen such a bi-stable heart rate before. I don't remember how long it was before it resolved.

I remember, immediately after the second ablation and before the catheter sleeves were removed, Dr. Natale was either puzzled or displeased by how unstable my heart rate was. The unstable heart rate more or less resolved within a week or so.

After the second-ablation-two-month-post-ablation-medication-period and until five months after the second ablation the measured irregular rhythm time per 24 hours was erratic and ranged from zero to eight hours per day. Subsequent to the five month post-second-ablation-time and prior to the 18-month-post-second-ablation-time the measured irregular rhythm time per day was zero. During the last five months it has again become erratic and has ranged between zero and one hour per day.

I'm sure the bi-stable rate was not present before I went directly into permanent a-fib six years ago, and it was not present in my ECG data during the day after each cardioversion (pre-ablation) before I reverted to a-fib. While anything is possible, I'd say: (1) the evidence; and (2) plausible explanations for how a bi-stable pacemaker situation could result from an ablation, both suggest that creation of a bi-stable heart rate is a possible consequence of an ablation.

In Kagey's case this manifests as alternations between two rates because rate control alternates from one pacemaker to the other, while in my case it manifests as alternations between irregular rhythm (when the two pacemakers are competing for control) and stable nsr when one of the pacemakers goes dormant.

I continue to wish that successful ablatees, who have experienced episodes of "a-fib" long after their ablations, would check in and report whether their episodes of "a-fib" were confirmed with an ECG. These reported episodes may not have actually been a-fib, even though the irregular rhythm experienced would have seemed exactly like the irregular rhythm a-fib produces.

Thanks. I understand now why you are sure this began to happen after the ablations, and specifically after the first one. Do you think many people would have the data available to tell whether this same thing was what was happening with them too, or not?
PeggyM

Peggy and Wil. I am sure that very few people would be set up to see such things, unless they were very persistent with Holters - or invested in their own setup, as Wil has. In my case I had to work hard with the physician's office to "capture" my two separate sinus rhythms, and the probability of catching the typically short irregular transition (competition) times would be very, very low, except with a Holter. In my case the two stable rhythms are typically stable for hours up to several days, and to capture a transition would require real patience on everyone's part with a Holter -- or ownership of your own Holter setup.

I do assign importance to Wil's point that relatively short bursts of irregularity post-ablation should not be assumed to be a-fib without documentary records.

Another question to be asked: in both my case and Wil's, the AF prior to the ablation was long-standing 24/7 (in my case 3 years prior to just one ablation, I'm not sure if Wil was in 24/7 prior to his second...). Do our situations have anything to do with underlying changes that occur in 24/7, but not in paroxysmal? I do not expect to see an answer to that last question in my lifetime!

Kagey

My sequence was abrupt transition from long term nsr directly into permanent a-fib six years ago. A couple of cardioversions only lasted 24 hours and thereafter didn't work. After four years of permanent a-fib I had the first ablation, followed by 8 weeks of medication, followed by continuous a-flutter. A second ablation was successful and produced the history outlined above.

If there is a connection between ablation, after long term permanent a-fib, and the appearance of multiple pacemakers, one guess would be that fixing long term permanent a-fib requires creation of scarring closer to the SA node, which could increase the potential for creating alternate pacemaker tissue.

Why is no one checking in to tell us whether their "a-fib" episodes occurring months or years after successful ablations were verified by an ECG?

"Why is no one checking in to tell us whether their "a-fib" episodes occurring months or years after successful ablations were verified by an ECG?"

Maybe because they weren't.

PeggyM

Seems nobodys paying us no mind...

What is the origin of the name Kagey?