Lots of PACs one month after ablation - does is mean that the ablation did not work?

Dear Friends,
I had an ablation at UC Irvine on April 28th (technical notes of the EP below).

I convinced my EP to keep me on flecainide after the procedure. Still taking eliquis, flecainide 100mg BID and diltiazem ER daily.

I was doing great for about a month then Sunday all of sudden my HR jumped from 60 bpm to 108bpm out of the blue (I was sitting), and started feeling a lot of palpitations (two beats in row, probably PACs). I went in for an EKG yesterday, and it shows elevated HR but NSR. I have been in this elevated HR since Sunday and lots of palpitations, which feel all day long. My apple watch shows a PAC every five or so beats. I have not been able to talk to my EP about this - I left him messages and phone calls but he is ignoring me. I have an appointment at the end of next week.

I know that during the blanking period, these events could happen but I expected them to be a few minutes, maybe hours. It is has been three days now. Does it mean that the ablation did not work?

Stefano

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Procedures performed:
Cryoballoon catheter ablation of atrial fibrillation (pulmonary vein isolation)
RF catheter ablation of atrial flutter
3D electroanatomic mapping of left and right atrium
Intracardiac echocardiography

Findings/Conclusions:
Pulmonary veins isolated by cryoballoon technique with demonstrated entry block

Procedure in detail:
Anesthesia: general anesthesia
Vascular access: right femoral vein 12 Fr FlexCath Advance, 10 Fr, 7 Fr
Catheters used: Dynamic decapolar 6 Fr, 9 Fr ViewFlex Xtra ICE, Medtronic Achieve 15 mm, Medtronic Arctic Advanced 28 mm, Tacticath D/F
3D electroanatomic mapping system: EnSite Precision

Groin access was obtained as above after application of local anesthetics. After insertion of sheaths, heparin bolus was given and drip started to maintain ACT 300-350 seconds. All sheaths were attached to continuous heparinized flushes. The decapolar catheter was placed into the coronary sinus for left atrial recording. Stability of the position was confirmed.

An intracardiac echocardiography catheter was advanced to the high right atrium. The short 8 Fr sheath was exchanged over a long wire for an SL-1 sheath. With the SL-1 at the high SVC, the wire was removed and the dilator was aspirated and gently flushed. The SL-1 was then loaded with the BRK transseptal needle. Under fluoroscopic and ICE guidance, the whole apparatus was then dragged down from the level of the SVC to the fossa ovalis area. Engagement of the fossa was visualized with ICE and fluoroscopy (RAO and LAO views). Tenting of the interatrial septum at a anterior/mid position was confirmed with ICE. At this point, the needle was advanced out of the transseptal sheath into the left atrium. RF delivery through the needle was not used to cross. Left atrial pressure waves were seen, with mean left atrial pressure 5 mm Hg. On ICE, saline flushed through the needle was seen to swirl in the left atrium. The sheath and dilator were advanced into the left atrium covering the tip of the needle, with gentle counterclockwise rotation to avoid the posterior left atrial wall. The sheath was advanced into the mid-cavity of the left atrium with slight clockwise rotation over the dilator and both the dilator and the transseptal wire were removed.

The SL-1 was exchanged over a wire for the deflectable sheath. During the exchange process the sheath was inadvertently pulled back to the left atrium. After a brief attempt to pass the cryo sheath over the decapolar catheter into the left atrium did not work, the cryo sheath was removed, replaced with a 14 french outer sheath and another drag was performed with the SL-1 as above. The sheath crossed without extending the needle, and after exchange the cryo sheath was advanced into the left atrium easily.

The Achieve circular mapping catheter and ArcticFront Advance second-generation cryoballoon were introduced into the left atrium through the deflectable sheath. Geometry was collected in the left atrium with the Achieve, and integrated with the patient's segmented cardiac CT scan using the 3D electroanatomic mapping system.

To ablate each pulmonary vein, the Achieve was advanced into the vein. Geometry was collected, then the cryoballoon was advanced over the achieve to the proximal antrum. The balloon was inflated and, with the use of contrast venography and color flow Doppler ICE as needed, the position was adjusted until adequate occlusive contact was achieved. Cryoablation was then initiated. After the last cryo lesion was placed in each vein, the Achieve was withdrawn to the vein ostium and no pulmonary vein potentials were observed.

The esophageal temperature was monitored during ablation. Lowest observed esophageal temperature was 33 °C.

During ablation of the right-sided veins, the phrenic nerve was paced from the RA/SVC junction, superior to the level of the freezing surface of the balloon, using the decapolar catheter. Diaphragmatic contraction was monitored using palpation and fetal heart rate monitor. Diaphragmatic contraction remained strong.

After the last cryoablation lesion was delivered, the Achieve was moved sequentially to each pulmonary vein. All of the veins remained isolated with observed entry block.

The sheath was pulled back to the right atrium.Because the patient had documented typical atrial flutter, a CTI line was performed. A tacticath d/f was inserted and the line was created from the tricuspid annulus to the IVC. 35 Watts, max 42 C. Transisthmus time increased from 70 to 150 ms bidirectionally and remained blocked after 15 minute waiting period. Block was further ascertained with 3d electroanatomic map of the right atrium.



Edited 1 time(s). Last edit at 05/25/2023 06:15AM by SteLo.

No, it does not mean that. Ectopics following an ablation are very common and so is an elevated HR, though 108 is a bit high. Does it stay that high for prolonged periods even when you're at rest?

Hi Carey,
thanks for your reply -- that's very reassuring.

My HR has came down. When I am at rest my HR is 75-80 bpm (used to 50-55 bpm before the ablation).

I am having a LOT of PACs during the day, a lot more than I ever had. They are generating a lot of anxiety
because they used to be a prelude to Afib/flutter (before the ablation). I hope they subside soon.

Thank you,
Stefano

PACs can be persistent and annoying as hell, but they're harmless and will most likely settle down at some point. Many people here have had good luck taming them with magnesium supplements. Search the forum for posts about magnesium and you'll find a ton of them.

Want to give an update 10 days after that episode of tachycardia.

My HR has calmed down - a little lower every day, and the PACs have diminished in intensity and frequency.

Keeping my fingers crossed.

Thanks for the support,
Stefano