Increased. PACs starting 6 weeks post ablation

Hi everyone-
I had my ablation on 9/12 with DiBiase and woke up feeling like a new person. Afib had gotten so bad I was having daily episodes that made me unable to drive. My first ablation was with him in January of this year- held until summer. I’m young and hadn’t had afib long. First lesions held fine- so he ablated second area. Last thing left is the lCC and hoping doesn’t come to that. Post surgery only Eliquis and cardizem (I can’t take anti rhythm). Ectopics started at 3 weeks, they seemed to slow a bit,’or I got used to them. At 4 weeks they lowered my cardizem dose as I was getting dizzy- had lost weight and lowered bp which was likely the issue. 5-6 weeks on its daily ectopics. I’m 9 weeks post ablation now. I went to local EP yesterday and EKG confirmed PACs and she heard one with the stethoscope. They increased my cardizem a bit and think that may quiet it down. I got the normal bit about this being normal and not dangerous.
I can live like this frankly- I’m a thousand times better than I was pre ablation. But I’m terrified this activity means I’m heading to get the LAA done. I’ve seen the studies on PACs as predictors of more afib, etc. I’ve had them since 3 weeks post-op-and in retrospect suspect they increased once we lowered the cardizem- it just took me this long to figure that out. I know I can only control diet, supplements, etc. and hope for the best. Has anyone had this issue and did it eventually improve? I’ve seen online where a few people said it was at a year or more that it quieter down. I didn’t even make it 6 months after my first ablation before it jumped to another area of my heart- and that started as pvcs before it triggered afib- so I’m concerned. Probably just venting as I realize I have little control Over this. I also wonder can this keep happening- or is LCC ablation at least the end of the road?

By ‘ICC’, ‘LCC’ I presume you mean LAA? If so IMO you’re a long way off needing LAA ablation. Lots of folks with successful ablations still get a lot of ectopics - in fact I’d go as far as to say most folks. The main thing is the ectopics don’t lead to AF.

Yes LAA- typos. It’s just that as soon as this happened last time it all fell apart and I had far worse afib than I ever did before the ablation. Was told the LAA is the only place left for it to jump to. I would be just find with ectopics that led to nothing more- and your post gives me hope that that is likely. Thanks!

Until you actually experience afib again I think you're inventing things to worry about. And speaking as someone with an isolated LAA, I don't think it's anything to fear. Yes, if you end up having it isolated and if it doesn't contract adequately afterwards you'll either have to remain on anticoagulants for life or have an occlusion device/procedure, but that's nothing to fear either.

Since my ablation in Bordeaux over 15 years ago I have been in nsr. But I get many many ectopics, almost 8000 on a 24 hour Holter, which don’t trigger AF. The docs say they’re harmless but I could take a small dose of bisoprolol if they bother me.

They used to be very uncomfortable, like being kicked in the chest every few minutes, but if I take magnesium, potassium and taurine every day that seems to dampen them down so I hardly feel them at all. I’m happy with that!

Gill (pronounced 'Jill' and female)

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Gill
Since my ablation in Bordeaux over 15 years ago I have been in nsr. But I get many many ectopics, almost 8000 on a 24 hour Holter, which don’t trigger AF. The docs say they’re harmless but I could take a small dose of bisoprolol if they bother me.

They used to be very uncomfortable, like being kicked in the chest every few minutes, but if I take magnesium, potassium and taurine every day that seems to dampen them down so I hardly feel them at all. I’m happy with that!

Gill (pronounced 'Jill' and female)

Do you have more ectopics depending on your body position ? Say, when laying down or leaning forward... things like this.

Hi Gill - I'm so pleased for your excellent post-ablation success.

Although I've had three ablations, I was never bothered with ectopics and most likely because I kept up with the magnesium, potassium and taurine...as you mention.... esp. the magnesium as my stress level tended to deplete that rapidly. Because of the stress impact, I also continue supplementing with adrenal support nutrients as advised by my functional medicine MD. For me, that makes a huge difference in overall well-being and definitely helps maintain a very calm heart.... even with postural changes or during workouts at the gym.

Jackie

Pompon

They follow a similar pattern to to my AF before it became persistent - I get loads, then it’s almost as though there has been a discharge of electricity and everything goes quiet. After a few days I get occasional ones, then they gradually build up until there is another 'discharge'. Nothing seems to change that pattern.

Gill

My heart went nuts with ectopics for almost a year post-ablation. What you're experiencing is nothing unexpected after just 6 weeks. I'd suggest you use the time to carefully adjust supplementation to get yourself in a good zone for the long term.

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Gill
Pompon

They follow a similar pattern to to my AF before it became persistent - I get loads, then it’s almost as though there has been a discharge of electricity and everything goes quiet. After a few days I get occasional ones, then they gradually build up until there is another 'discharge'. Nothing seems to change that pattern.

Gill

I once suggested this analogy with a battery charging and discharging, because after an afib episode (the discharge), I was sure to be afib free for a couple of days (the recharge). There was such a pattern.
Now, it's already different, which means the behaviour of my vagal tone and the reactions in my heart chambers are evolving.
October was bad month for me, with 14 afib episodes (from less than 1/2h to 2h, just one of them lasting 4h15).
I've only experienced 3 episodes in November (1, 2 & 4 Nov.), so I'm now afib free for two weeks, but I've still lots of ectopics. Particularly when laying down. I'm used to them, but I know they can turn to afib, which is not reassuring.

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Pompon
I once suggested this analogy with a battery charging and discharging, because after an afib episode (the discharge), I was sure to be afib free for a couple of days (the recharge). There was such a pattern.
Now, it's already different, which means the behaviour of my vagal tone and the reactions in my heart chambers are evolving.

I also experienced that pattern for many years. In fact, I could feel it. I knew when an episode was coming. The analogy I used was tectonic plates. Pressure builds and builds until eventually the plates shift and an earthquake occurs, relieving the pressure.

But I'm not so sure vagal tone has anything to do with it. I've asked a couple of EPs if they could explain the phenomenon and they could not.

Pompon… If you haven’t read this report by Patrick Chambers, MD…(aka PC) who was an active participant for several years when he was an afibber, you may find something here that is similar to your situation… Dr. Chambers does address vagal tone and that topic was very much a consideration for many years of post threads.

[www.afibbers.org]
and this contribution by PC starting on p. 18.

[www.afibbers.org]

This one has multiple observations and references in the first 5 pages… plus more later.
[www.afibbers.org]

PC talks about Right Side Left Side and vagal tone in this one
[www.afibbers.org]

This one by PC starting on page 28
Pre and Post Ablation PACs
[www.afibbers.org]

I stopped searching at Session 50…
You can continue at this link for more
[www.afibbers.org]


Jackie

It may not be the vagal tone by itself, but it's obvious that the vagus nerve is highly involved in those troubles.
Each time I feel ectopics or afib, it seems that my vagal tone can't keep the control of my HR because it has to fight against opposite informations trying to make their way to my brain. I'm no scientist, it's just the way I feel the troubles in my chest.

Edit : I must add that the opposite informations seem to come essentially from my stomach.



Edited 1 time(s). Last edit at 11/20/2018 07:44PM by Pompon.

Thanks for the Links, Jackie. I've now to take the time to read...

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Pompon
I've only experienced 3 episodes in November (1, 2 & 4 Nov.), so I'm now afib free for two weeks, but I've still lots of ectopics. Particularly when laying down. I'm used to them, but I know they can turn to afib, which is not reassuring.

I should not have written that.
Lots of ectopics this night, kicking afib at 7:00 am. I took my flec at 7:05, back to NSR 15 min later. Obviously, the flec got not enough time to act, but things are quiet now, no ectopics at all, which may eventually be an effect of the flecainide as well as the fact that the "battery" is depleted.

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Pompon

I've only experienced 3 episodes in November (1, 2 & 4 Nov.), so I'm now afib free for two weeks, but I've still lots of ectopics. Particularly when laying down. I'm used to them, but I know they can turn to afib, which is not reassuring.

I should not have written that.
Lots of ectopics this night, kicking afib at 7:00 am. I took my flec at 7:05, back to NSR 15 min later. Obviously, the flec got not enough time to act, but things are quiet now, no ectopics at all, which may eventually be an effect of the flecainide as well as the fact that the "battery" is depleted.

Are you sure it was afib and not runs of eptopics?

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rocketritch

Are you sure it was afib and not runs of eptopics?

Well, sometimes it's hard to Say, because I've runs of ectopics as well as afib. As it was worse than usual last night, I stood up and took the time sticking electrodes and recording some sequences.
I'll post some tracings tonight.

Here we go...
Tracings captured with lead wires in "MCL1" configuration (neg under the left clavicle, pos in V1, gnd under the right clavicle).


1°) Around 1:30 AM. Obviously, runs of ectopics. In the 3rd line, 1 left PVC ?


2°) Some minutes later. PVCs (bigeminism) ?


3°) Around 7:05 AM. Felt like afib. Looks like afib on the tracing. Isn't it afib ? (+ 1 PVC in the third line ?)


4°) Around 7:15 AM. PVCs and runs of PACs ? Some minutes later, I was back in NSR.

1) Afib
2) PACs in a bigeminal pattern
3) Not afib, probably flutter
4) Afib with a couple of PVCs

Carey, would you explain a little? I like to understand...

1) There are p waves. Why is it (unsustained) afib and not runs of ectopics?
2) OK.
3) Is it atypical flutter ? It's irregularly irregular. It looks like what I see in 4), but it's not interrupted.
4) Same question as for nr 1.

Thanks.

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Pompon
1) There are p waves. Why is it (unsustained) afib and not runs of ectopics?
2) OK.
3) Is it atypical flutter ? It's irregularly irregular. It looks like what I see in 4), but it's not interrupted.
4) Same question as for nr 1.

1) Yes, there are a few P waves but they come and go the same way the regularity comes and goes. You can call it runs of ectopics if you want but that's just semantics. Looks to me like you were wavering in and out of afib.
3) No way to tell if it's flutter at all without a 12-lead, never mind typical vs atypical. Flutter is just the most likely explanation.
4) Same answer from me on #1.

You know, having a mix of afib and flutter is really common and I think that's what your recordings look like. I did, and I've got a zillion recordings that look a lot like yours. It would start with some funky ectopics, then afib would start, and then it would convert to flutter, and then maybe to NSR for a while, then back to afib again. Lather, rinse, repeat.

Don't drive yourself crazy trying to identify exactly what rhythm you're seeing. I think you're seeing a bunch all mixed together.

Thanks, Carey, it's clearer now. Those disorders are very common for me. I don't record them very often. The purpose for doing this is showing my docs what happens frequently except when they take a routine 12-lead ECG. The question I'm usually asked is "are you sure they were not some ectopics ?"

For me, 1), 3) & 4) give the sensation of afib. The difference comes from the breaks in SR for 1) & 4), and I'm used to call them "unsustained afib".
Nr 3 is common too, for me, and I sometimes wonder if it's not SVT (I've experienced it a couple of times), but it's different. SVT is regular. Here, it's not and I feel it.

I can live with some ectopics, but the bigeminal pattern as in ex. 2 is a really bad sensation.



Edited 1 time(s). Last edit at 11/23/2018 11:36AM by Pompon.

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Pompon
I can live with some ectopics, but the bigeminal pattern as in ex. 2 is a really bad sensation.

I know the sensation very well. I used to experience bigeminal PACs that would last for weeks at a time, so I sympathize with you. I've got a stack of Kardia readings that look just like your #2 recording.

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Carey

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I can live with some ectopics, but the bigeminal pattern as in ex. 2 is a really bad sensation.

I know the sensation very well. I used to experience bigeminal PACs that would last for weeks at a time, so I sympathize with you. I've got a stack of Kardia readings that look just like your #2 recording.

I've experienced horrors like this for hours :



I don't think those PVCs are dangerous, but you know how one feels when they last for hours...

Those are actually PACs, not PVCs. PVCs are bigger and wider since they originate in the ventricles. But you're right that they're not dangerous, just really aggravating.

Don't they look like the PVCs in the tracing n°4 here above ?

On closer examination (and after flipping your image to the normal orientation) you're right, that is bigeminal PVCs. Yeah, that must be uncomfortable.

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Carey
On closer examination (and after flipping your image to the normal orientation) you're right, that is bigeminal PVCs. Yeah, that must be uncomfortable.

Probably a little confusing because of the MCL1 positioning. They're a bit wider when displayed in a more conventional lead II tracing.
That said, I'd have liked them to be PACs...

Bigeminal PACs feel crap too since rage ventricles are beating in sync with them.

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mwcf
Bigeminal PACs feel crap too since rage ventricles are beating in sync with them.

My hope is that, in case they are PACs leading to afib, an ablation touch up could help getting rid of both in the same time.
I guess there's no chance doing this with PVCs..

PVCs can often be ablated.

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Carey
PVCs can often be ablated.

This means going down passed the valves? Not very reassuring, IMO...

As with all ablation procedures, reassurance is in the person who's holding the catheters. Ablation of PVCs, v-tach, and other ventricular issues is a fairly common procedure among advanced EPs.

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Pompon

PVCs can often be ablated.

This means going down passed the valves? Not very reassuring, IMO...

It does. The good news is PVCs can be very focal, meaning just a little burn is required. It’s not a “scatter plot” like the left atrium can be. The operator does need to be careful not to tear or damage the valves, however. Yet another reason that skill matters.

Thank you both for your answers.
Can EPs induce PVCs as well as they can with afib for ablation purpose ? I'm asking because I'm scheduled for an afib ablation touch-up this week and never asked for any procedure against PVCs, my main concern being to get rid of afib and meds. But, since my PVCs are more than probably induced by digestive problems, would they appear during an ablation procedure that's done while my stomach is empty and, in this case, would they come from the real ectopic points given they are artificially induced?

I don't believe PVCs can be induced, but what makes you think they're due to digestive issues?

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Carey
I don't believe PVCs can be induced, but what makes you think they're due to digestive issues?

When they appear, they always come with stomach bloating. Burping helps reducing the pressure. I'm more prone to get PVCs when my body position squashes my stomach. Typically when sitting at my desk after meal, or when I've to work at home at or near ground level.
At work, I try eating small quantities at a time and standing up when things go wrong. Not always easy.
It seems those PVCs tend to induce PACs and PACs sometimes induce afib. Fortunately, all those troubles are of short duration, but who knows how they could behave in the future?
Sometimes my heart makes me think it's like a rotten roof : repair a hole, another one soon shows up and the water creeps in. If one can't replace the roof, may I hope it'll not rain ?
Two months ago, I've had an appointement with a Chinese pratician. Why not have another opinion, after all? At once, after having heard my story, he said the culprit was my liver. He talked about the Yang of my liver and the Yin of my lungs - something like this - fighting against each other. I've met him four times after that, for some acupuncture. It doesn't help. But I'm feeling he's right about my liver. He's the first pratician telling me such a thing. Others I met for my digestive problems told me they could be linked with HR disorders or induce them, and they prescribed IPPs for my GERD. They're worse than anything and I don't take them any more for a long time.
The Chinese pratician told me about food I have to avoid eating. It's a low fat low carbohydrates diet, without acid fruits like oranges and baked tomatoes. Mushrooms are bad too, but I've not asked why.

Pompon - there is definitely a connection between 'gut' issues and the promotion or stimulation of AF for some individuals. Check this report from long ago on by Professor Steve Rochlitz about vagus nerve imbalance and hiatal hernia influence. It's a long collection of relevant observations, but in practice, it does work so read through to learn all you can. [castlehighkingdom.proboards.com]

Dr. Rochlitz 's book... www.amazon.co.uk/Hiatal-Hernia-Syndrome-Vagus-Imbalance/dp/0945262612

And this website - [wellatlast.com]

Jackie

Thanks for the links, Jackie. It's always appreciated.

(I'm back home from my 4th ablation procedure - more about this later...)