PACs Again After Cardioversion

Was cardioverted from my Aflutter Thursday 4/27 and I've since been observing my heart rate calming down. The first day it was noisy and rapid but looked like NSR under it all! Today my resting heart rate is down to the mid/lower fifties where it was before the afib/flutter took over. But the PACs were occurring every 2nd, 3rd, or 4th beat! (Bigemeni, trigemini, quadrigemini)

I check my resting heart beat every 2 days or so on my "ReadMyHeart" ECG display (lead II equivalent). My heart is calmer and in NSR but I can see many PACs with normal upright P waves occurring and no PVC's. When checking my pulse during more active times, the PACs seem much less which is some comfort but without a treadmill ECG it's very hard to tell. My main concern is so many PACs seen during resting.

Where do these ectopics come from? Going back to my talk with Shannon in March, he believes there are new ectopics coming from the left atrium and these PACS seem to fit that category. These trouble spots can turn into afib/flutter trouble spots (agree?) Thirteen years ago Dr. Natale didn't ablate LAA or CS areas (left atrium) and that well could be the new source of trouble. My EP thinks the source is from the left atrium also but of course can't be certain. Correctible by another ablation yes, but I'm 81, and my cardiologist thinks I'm too old for that. My EP did the cardioversion and would like me to go slow and see if medication might be advisable.

I've changed some nutritional input per Jackie's sage advice, but was into magnesium & potassium plus other supplements for years. 800 mg Mg/day is my recent practice. Also taking only 200 mg of K as I didn't do a Exa test or know how to tell if more was needed. Now using a bit of Hans' "PAC tamer" recipe I'll be "blindly" adding some K to my system. Does anyone know if Hans' recipe ever worked for taming PACS? Coincidentally my PACS have shown some improvement so I'm tempted to let more time elapse and wait & see. My age, recent muscular, joint, and tendonitis problems, and some subtle changes in my heart traces make me question if my body needs a re-ablation. I do have a Dr Natale re-ablation appointment in late June but it's a hard decision to go through with it!

To add to my confusion, I did get a call from a study group located in St David's that was asking me to be in a group of ablation patients who would take a cognitive performance test before and after ablation! I did later Google that topic and found there was a serious concern. OMG if I loose any more cognition my wife will have to lead me around with a leash ! heh, heh

Any replies welcome, Anton

Anton

i wouldn't have any worries about my cognition if I could write as elegantly and fluently as you do in your post!

Gill

Hi Anton - I can appreciate your concerns about ablation at age 81. If it's any comfort, I had my Natale ablation #2 at age 78 which was the LAA isolation and all. Then a followup #3 about 8 mos later at age 79. Other than the typical residuals I usually have after all the chemicals, I had no major problems. I didn't lose mental capacity although for a period of time my memory seemed a bit less functional. You can certainly push your date out for a while if that would make you feel better. I'll just say that I probably held off too long before waving the white flag on my second ablation timing because the majority of events were A-flutter and they rarely converted w/o ECV which was always an ordeal.

Leading up to the second period of breakthroughs, I didn't PACs. It just slammed into Aflutter.

Keep your magnesium intake optimized... just below the bowel tolerance level and remember that the recommended daily intake from food for potassium is 4700 mg. so make a chart and figure out where you are.

I've sent you a PM.

Best to you,
Jackie

I've had a number of ECV's, and some work better than others, sometimes like yours, I get many PAC's, most of the time I am smooth NSR afterward. Curious Anton, where did they place the Paddles? Front and back of chest, or right chest and under left arm?

Front & back of chest. No details yet if 1st try was the successful one.

Looking for new ideas on PACS-- location and how best to limit or stop them.

(i.e. upright p-wave PAC probably left atria focus; best way is potassium)

PAC's are dependent upon body position, so you might check for PAC's in different sleeping positions, or sitting position.
Mine also got better with low-key exercise, like walking.

Keeping a Log or AF Diary might also help. Record BP, and Oxygenation saturation level if you have a Pulse Oxymeter, when these PAC's are occurring to compare to periods of smooth NSR.

Anti-Fib, Thanks
Sleeping body position somewhat limited but have noted LHS position less favorable. Low key exercise does improve PACs a little but not too significant (yet)

Lots of day by day data but no significant reduction in PACs. I take 1 lead strip (resting) about every other day. I would call "significant" a 50% drop which would still be over 10000/day. But since I believe the PACs drop significantly with mild exercise that would be much lower for the full day. I presently tolerate them very well but PAC reduction still very important as they are a precursor to Afib or Aflutter.

Anton - keep in mind that PACs represent the shortening of the refractory period or the time between beats involving the repolarizing phase or the action potential when the cells/muscle can't be stimulated. The idea is to prolong the refractory period so the time between beats is longer and 'normal'...rather than PACs.

The many posts we've had on the topic of the role of potassium with PACs including Conference Room 72 on the ratio of Potassium to Sodium... emphasize the importance of
1) making sure you have optimal intracellular magnesium which can then support the role of potassium.
2) monitor dietary intake of sodium to be sure your sodium level is not overpowering potassium
3) if your dietary intake of potassium falls short of the 4700 mg daily, then supplementing potassium or drinking organic veggie juice and other potassium-containing foods and can help keep the potassium levels at or close to where they need to be to prevent PACs. It's helpful to do a food diary log to see what your potassium intake actually is.


CR 72 [www.afibbers.org]

Excerpt: Na/K pumps span the cell membrane, and generate the
electrical voltage (potential) to charge the cell/battery by
continuously pumping ~3 Na+ ions out of the cell in exchange
for ~2 K+ ions pumped in.[5, 6] In cardiac muscle a
'trans-membrane potential' of about 90 millivolts (mV) is
generated (negative inside), which provides for the cell's
electrical requirements: voltage-gated ion channels, calcium pumps,etc.

To attain this functional voltage requires the intracellular K/Na ratio
to be at least 20 to 1 [7], which in turn requires the dietary K/Na ratio to be at least 4 to 1.[1]

The kidneys ideally maintain serum K and Na at the levels they
were evolved to maintain, but the high intracellular K/Na
ratio can not be attained if intracellular Na is too high.
(as Dr. Moore explains, above).

Also review the CR 74 discussions on the Cardymeter for monitoring potassium levels.
[www.afibbers.org]

Jackie

Thanks Jackie

Good info to research (I'm dancing as fast as I can)

Interesting as my PACs are almost exclusively outside the QRST period which includes the absolute, effective and relative refractory periods. Except for a few PACs in the latter third of the T wave, most of mine occur in the remainder of the RR period and are usually about .2 -.4 sec later. (resting HR in mid 50's) (hard to tell just feeling pulse) That latter third of the T wave is a hyper-excitable period "where even a weak stimulus can cause an action potential".

So most of my PACs are benign and very tolerable but a possible precursor to Afib/flutter. Phew! [Im still dancing as fast as I can...but I'll try to absorb the rest later]

Regards, Tony

Tony,

Nice talking with you again today, Thanks for the EKGs too, though it is not a complete 12 lead. The PACs are a residual of the underlying flutter circuit that caused the recurrence of arrhythmia 13 years after your very successful index ABL with Dr. Natale. This pattern is a classic very late recurrence after 10 plus years of a stable heart after an early years a the successful Natale PVAI... As I noted, you can basically take it to the bank that this flutter that is temporarily in an unsteady ectopy laden Sinus will not last indefinitely and will almost certainly return. The odds are very high ... almost 100% certain ..: that your original ablation lesions are still solid and thus this new active left atrial flutter is surely from the Coronary Sinus (CS) and Left Atrial Appendage (LAA).

This flutter and ectopy has no correlation to someone's experience post cardioversion who has never had a successful PVAI previously. They are two very different scenarios.

It is definitely good to redouble your efforts to replenish your magnesium/potassium as it will only help overall cardiac stability, but almost certainly it will not be enough to quell the now awoken atypical left flutter long term.

You can certainly decide, as a viable option at your age, to not get this CS/LAA isolation and just stick with rate control and/or perhaps Tikosyn that could restore NSR for a period of time but that is VERY unlikely to be a real long term solution. If a person in their early 80s has poor health it may be a good choice to stick with rate control. But if you are still vital and looking forward to another decade plus of embracing life as much as possible and within reason for a healthy 80's living person, then that argues strongly for completing this last phase of the expert ablation process with Dr Natale you started almost 14 years ago.

Like I said on the phone Tony, there is no wrong choice here, I only want you to be fully informed about both choices so you can make the best choice for you.

Be well,

Shannon



Edited 1 time(s). Last edit at 05/15/2017 03:04AM by Shannon.

Thanks, Shannon for the clarification on Tony's recurrence.... which was my problem as well.

The flutter for me seemed unaffected by the intense efforts with Mg and K and all the other supportive nutrients I added in the hope it would make a difference. My flutter events were severe and frequent so while I was naturally a bit apprehensive, I didn't have much choice as I was getting pretty much non-functional with recurrent bouts that seemed unaffected by ECVs.

Jackie

Thanks Jackie,

And yes indeed, your experience is a big reason I do recommend getting the followup ablation for a person like Tony who is in otherwise good shape and has had 13 years of Blessed NSR from his first Natale ablation.

The typical Cardio and most clinical EPs mind set who are not at the elite level of ablation researchers and nor do most of these well-meaning folks have a lot of experience with elite level ablations, results in them making some general assumptions that are not often true and thus some of these docs will make 80 or so the cut off age, but it is NOT an age decision primarily it is far more a decision based on overall health and lack of co-morbidities as ones age that matters most with regard to recommending an octogenarian ablation.

From taking to Tony he is not 'an old man with one foot in the next life' by any means from the mental or physical perspective ... far from it. And there are a number of well done studies from Natale's group, University of Penn and Bordeaux as well as Japan and China too I believe validating the safety and efficacy of octogenarian AFIB ablation.

Again, the decision will include a careful assessment of any other co-morbidities any elderly person may have, But for those like so many on our forum who have taken pretty good care of themselves and are still looking forward to waking up each day and getting the most out of the next 10 years, or however many any of us are blessed to enjoy, then all I can say is one's quality of life is MAJORLY boosted by living in NSR .. there is just no great substitute for NSR.

Thus in my book, If Dr Natale feels that a given person has too big a risk he would say so and would offer other management methods with medications and such and then I would listen to him too and not push for it.

But for any octogenarian that passes Dr Natales consult and he is recommending such a follow-up ablation, then I'd definitely recommend giving it strong consideration. Statistically, it is not really any riskier than doing an ablation at 60 years old. As Jackie noted, it can take a month or two to fill more or less fully back in the saddle, but for much of the last weeks of that recovery period you should be feeling steadily better day by day for the most part. Mostly, I think it can take older folks a bit longer to process all the anesthesia meds, but once past that and enjoying unbroken NSR again, I dare say the vast majority of such 'golden oldies' will find it to have been well worth the effort.

Shannon

Special Thanks to Shannon and Jackie!

Shannon, Thank you so much for the call. The first ECG copy I sent would have been the only 12 lead trace. It shows the forward leads II, aVR, & aVL as having low voltage (>.5v) which has been noted since my cardioversion on another 12 lead tracing. It also shows an incomplete RBBB in leads V1& V2 which is an old "problem" but ok as long as it stays incomplete. If this 1st trace you received does not show all leads, I can resend. The low voltage, which you said you have seen in your ECGs also, is certainly not a deal breaker. It can be an indicator of less force from the ventricles but I should get an echo measurement of my present ejection fraction as an additional force indicator. I agree my efforts to improve my low potassium/sodium ratio is probably not effective enough. I did send the 2nd single lead trace to show my typical PAC pattern and noted that the PAC "p" wave is upright and over 2x the voltage as the normal NSR p wave. (not sure if significant)

Jackie, Thanks for the Mg, K, and Na info and for stressing the all important K/Na ratio. BTW, WebMD just came out stressing the need for 4700mg of K. (up from old sources calling for 3600) My crude measurement of my K input seems low at about 3000mg/day so I've been increasing with diet and some supplement. I also cut my salt intake a bit as I've always had a low BP, and sometimes too low. As ever you are a fountain of knowledge to us all.

So considering my age and some questions about my aged heart, I am leaning towards a postponement of re-ablation. My NSR (with PACs) is holding and my efforts to increase activities daily hasn't hurt at all. I think an echocardiograph would give helpful heart info. I have another appointment with my EP in a few weeks who did the cardioversion and is very familiar with ablations. I'm staying away from my cardiologist who thinks I'm foolish and too old to consider ablation. Even if ablated right away, present protocols will keep me on expensive blood thinner (Eliquis) unless I opt for an additional operation to plug my LAA (which will have limited outflow from the ablation).

Thanks to all for letting me "vent" and giving me your support.

Anton

Anton - As long as you are functional and not plagued by prolonged flutter events, I think it makes sense to wait.
It's good that you have an EP who is knowledgeable. My experience with cardiologists and even some EPs is that unless they are actively in the EP trenches, they may not be helpful. Yes, they can oversee an ECV but often if their focus hasn't been directly on atrial fibrillation and the whole ablation scenario, they can make comments that aren't totally accurate or relevant which is understandable.

As for being too old, Shannon's statements are certainly appropriate regarding age and health status. I believe he commented some years ago about Dr. Natale doing an ablation on a woman in her 80's who did well and was back enjoying her tennis games...so it obviously is highly individual.

Best to you,
Jackie

Hi Anton,

My guess is that this current break after the ECV is relatively temporary but as Jackie said it certainly wont hurt to wait until that proves to be true and you trigger again into Flutter.

Besides, the vast majority of us will naturally have a hard time doing an ablation when we are in NSR as it is. Especially in a case like yours where you have been in such long term NSR of over 13 years now from your index ablation with Dr Natale. Thus your relatively short duration of this very late recurrence of flutter likely is not enough to inspire you to proceed for that touch up just yet, and as Jackie notes that is just fine too.

If I am right and this very late CS/LAA triggering is what is going on here, then there will likely be a time when your view might change again, if and when the flutter comes roaring back. Nevertheless, that could be some months or maybe even up to a year of so as an outside assumption during which time this ECV might possible hold down the fort for you and keep the lid mostly on the kettle.

My suggestion, is to revisit this decision only if, and when, that flutter returns as if and when it does, with a second such episode this long after your index ablation, then you can take it to the bank the cause is very likely these two frontier trigger sources of the CS/LAA. Sometimes when they just start to get active a good ECV can buy you come decent time, but just keep in mind if the flutter does return, and you have any inclination at all to get it fixed ... which you very well may in such a scenario if said flutter becomes a very frustrating drawn out experience as such flutters can be ... then you know where to go as it is. My advice would be to do all the good things to your body that I know you are aware of and see how it goes since you have not been in actual arrhythmia since your ECV, but don't procrastinate too much should the flutter come back and requires yet another growing line of ECVs to terminate into ever shorter durations of NSR going forward.

Here's hoping you will be a true outlier here as far as folks who have had a long term successful index PVAI ablation from 10 years Plus ago and then have a very late recurrence as mostly Atrial Flutter which very often is then all new triggering from the LAA.CS frontier areas of the two atria. Most such folks do best once that flutter comes back more than one or two times and it is clear they will need and ECV each time to restore NSR. Nevertheless, you may well prove to be an exception after going basically 13 years in NSR before the flutter recurrence happened. And certainly, at least until proven otherwise I am banking on you to continue doing well and arrhythmia free for years to come, just as you are! And if it turns out you would do better overall with that follow up to Austin, Im sure you will make the right decision then as well, either way I don't at all see a future for you filled with lots of annoying arrhythmia.

Cheers!
Shannon



Edited 2 time(s). Last edit at 05/19/2017 06:08AM by Shannon.

Anton

Since my ablation in Bordeaux in 2003 I have had continuous nsr but am plagued by large numbers of ectopics - one 24 hour Holter showed almost 8,000. It was like being kicked in the chest every few minutes and very uncomfortable. The docs told me they were a nuisance but not harmful, and that I could take bisoprolol to stop them.

Following Jackie's advice I started taking magnesium to bowel tolerance, then added potassium and finally taurine. I thought the ectopics had disappeared but another Holter showed just as many, I just didn't feel them. When I take the supplements they seem to be dampened down and I hardly notice them.

Occasionally, if they get really bad, I take 1.25mg of bisoprolol but this is a rare occurrence.

Gill

Thanks Gill,

Your adding Mg should make the heart calmer and feel calmer as well. I've been taking Magnesium Glycinate "to tolerance" for years and for me, 800 mg is about there. Since cardioversion and Eliquis 100mg more seems to work, but not at all times. my Ectopics seem to be all PACs, and I barely notice them but check via single trace rhythm strip about every other day.

I've used taurine since my last ablation and have recently been adding potassium by diet and supplement to my intake but don't notice much, if any, improvement in PACs. I got out my calculator and figured your 8000 ectopics/day are about 5.5/min. and mine based on about 4 in 12 sec are 20/min or about 4 times more. (while resting) But without change, they are very tolerable but could lead to afib or flutter as I think they have in recent times. My diet has changed so will that prove helpful or as the joke goes--you may not live longer, but it will seem so.

Time will tell, Anton