PAC Ablate or not?

After consults with several EP's over the past few months concerning my high burden of PAC/PVC, that have been persistent for quite some time - here is my takeaways. By the way these are the "experts" from well-known centers. My Cardiologist, bless his heart, suggested that I just have everything ablated have a pacemaker - no medications needed.


1> PAC/PVC are not so benign for me - these buggers trigged my AFIB in the past, so that is a concern with my history. I have a LINQ and over the past year there were two instances of AFIB recorded, brief and self-corrected.
2 > Even with medication - I take two - Flecainide and Cardizem, they will likely fail in the long run to adequately control. I do not do well with BB. I keep increasing the amounts to have some relief. Side effects of course.
3> These are challenging to track down, so no guarantees that all triggers will be found, or I may develop new ones in the future - just like I was told when I had my ablations that AFIB ablations are not 100% guaranteed.
4> Having had 2 ablations already in the past 15 years - Mini MAZE with LAA closure and "touch up" ablation after mini maze, new technology since those would likely increase success. But this is unknown until mapping is done.

I have also discovered that many EP's do not like doing this type of ablation because of the time and patience it takes to do this. My local EP's have told me they have nothing to offer other than what I am doing or switch to Amiodarone. (UGH). That is the reason I sought out expertise outside of my local area. I have found two very experienced EP's from well-known centers who are willing to see what can be done and have good track records on challenging cases.

I have had AFIB for over 43 years (73 now) - that may be a record for the participants in this site. I have had excellent care and still here and would like to have whatever time left to have some quality of life. As we all know, this disease progresses. I am in good health and active, but the days when these are bad, affect quality of life. Should I wait until no other medication options are helping, or opt for this now? Thoughts?

Thanks

Tough decision. I agree that the flecainide and Cardizem are unlikely to be effective forever, and amiodarone is almost never a good long-term solution unless it's a life threatening condition, which this isn't.

What do the two EPs who are willing to "see what can be done" mean by that? I would imagine what they mean is they'll do their due diligence with a Holter monitor to see what your heart is actually doing (PACs, PVCs, or both?), and then if it's warranted do an ablation to try to find and ablate the sources. That's challenging work that's beyond many average EP's abilities.

I think you need to ask yourself how happy would you be with partial success. If they reduced the burden by 50% would you be satisfied? How about 25%?

May I ask you how often you have those ectopics ? And how long do they last when they appear ?
I'd like to know because I'm very often dealing with PACs and PVCs, sometimes with AFib, and wondering about another ablation...

Try Mag. Taurate Kal brand. It is doing wonders for my PAC burden.

At one point 10% burden via Medtronic linq recording with other various arrythmias thrown in before medication. With medication now on a bad day several hundred. Good day less than 50. Other arrythmias once a day or so.

Carey, both EP's have seen the LINQ data and would do a mapping study. They do know that it is multi focal in nature and a challenge. There is also a suspicion where these are coming from based on my history. I would be happy with any improvement - even with medication if they can't ablate all the sources.

I also supplement with magnesium Taurate - triple calm and take extra Taurate. I am sure it doesn't hurt. Plus many other supplements that are purported to be heart helpful.

I am reading more studies that a heavy burden of PAC is not as benign as once thought. The one specialist I spoke with told me that 1000 a day is of concern vs a higher level once thought.

The burden might be other daughters of the ectopic beats if they happen frequently, in runs lasting more than three or four minutes, and are detectible by the bearer. There is probably going to be anxiety, trouble sleeping, ruminating while trying to sleep or even during the day, and the resultant increase in corticosteroids. In turn, the persistent elevated corticosteroids will impact the immune system, notably interleukin II. Another child (might as well call this one a son) is increased adrenal activity which is thought to contribute to atherosclerotic plaque. It's hard on the endothelial cells lining the arteries, which makes them easier to deposit plaque onto.

My sister-in-law, a recent AF patient, was an oncology nurse her entire career. She impressed upon me the requirement to speak plainly to caregivers with emphasis on all of the lifestyle diminutions that come from whatever we're experiencing. Trying to impress them with your mastery of med-speak, or challenging their thinking or conclusions, doesn't help them to learn how badly the burden of AF has impacted your living...so-called living. It might not be a problem with anyone reading here, but I thought I'd mention that the physicians will respond positively in almost all cases where the patient claims to be suffering X because of Y. That tells them what they can do for the X and therefore the Y.



Edited 1 time(s). Last edit at 09/25/2022 08:43PM by gloaming.

I had an ablation 4 years ago to stop afib. So far so good. However I still get tons of PACs. In fact in a 30 min jog I will get almost 1400 PACs (pac every second to third beat). I also struggle after lunch every day. For whatever reason I get the PACs for several hours after lunch. What is a high burden? I figure I can have thousands of these every day and I feel every one of them.

Recent literature, there are many articles on this web site indicates that frequent PAC/PVC are not so benign as once thought. Last article I read the researchers stated anything over 300 a day should be investigated. PAC high burden can trigger AFIB. If you are in the thousands, I would check in with your EP or get another opinion if he/she is not interested in discussing. At a minimum, discussing some type of medication to control would be in order. If they do not bother you, that is one thing, if you are getting shortness of breath, dizziness, etc, that can be an issue. In any case suggest you do some homework.

I take 25mg metoprolol succ twice a day and 2.5mg amlodipine once a day. They help some but not very much. My EP’s position is basically how much do I want to tolerate. Because im somewhat younger he doesn’t want to start me on anti-arrhythmic drugs like flec. So I tolerate them as best as I can. Thankfully they seem to go away while I am at rest. If they ever get to a point where they keep happening all day long at rest I suppose I will need to try new drugs.



Edited 1 time(s). Last edit at 12/27/2022 04:26PM by sisyphus222.

Welcome to experimentation. There are other beta blockers that may work better - like bisoprolol. Personally I have been on Flec since I am 30, now 73, Also diltiazem as needed. I do not think the amlodipine does much for this. I have found that age is not necessarily a factor when finding out what works. As stated above at some point these drugs do not work well, then it is on to the next thing to consider. I hope you find an answer that works for you.

Thank you for the advice. My EP scared me when he said if I start taking flec I would be on it for the rest of my life. He made it sound like your heart becomes dependent on it so I got spooked. I am going to ask him about changing beta blockers to see if it helps.

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sldabrowski
Personally I have been on Flec since I am 30, now 73

I think you hold the record, at least among people on this site. It's interesting that it's worked for you for 43 years because flecainide is known to stop working for most people after some period of time, and usually a lot less than 43 years.

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sisy.phus222
My EP scared me when he said if I start taking flec I would be on it for the rest of my life. He made it sound like your heart becomes dependent on it so I got spooked.

I have no idea why he said that. Your heart does not become dependent on it. Many, many people here, including me, have started and stopped flecainide, some of us multiple times. And if it works well for you without adverse side effects, so what if you're on it for life? It's a cheap, generic drug that causes no long-term harm.

I have also had two ablations in the past 15 years, so I have been off and on Flec for all these years. I will likely need another ablation since over time the Flec becomes less effective and for me needs to be combined with another drug to get relief. Managing side effects of drugs can also be tricky. Sure wish more drug options were in the pipeline to help, since many folks do not want to go down the ablation path. Although it appears that the ablation path is much more profitable given all the advances and a longer term solution.