Sinus node dysfunction after successful ablation?

I have never posted on this forum before, only read posts.
I am scheduled for my first ablation in 3 weeks. I crossed from 2 and 1/2 years of paroxysmal afib to persistent afib four weeks ago when I went into a flutter. After a week I got a Zio patch and for the subsequent week it showed 100% flutter for the entire time. This is very different from any previous episodes where flutter always became afib and then SR would return. There were also pauses on the Zio patch report the longest over 6 seconds.The NP at the EPs office said pacemaker might be necessary. I was not expecting this. What I’m reading online says that a one week observation period would be reasonable before implanting a permanent PM if SN dysfunction showed up after a successful ablation. The NP seemed to indicate maybe 24 hours of observation. What should I think of this? I was not expecting to wake up from my first ablation with a PM.

Evelyn
I am similar to you with paroxysmal A Fib with periods of flutter followed by NSR. My pauses were discovered by EKG some 3 years ago and we took a wait and see approach and tried Sotolol instead of a pacemaker. Then last spring I complained of periods of what I called black outs and it was not caught on EKG's It kept getting worse and finally during a trip to the ER they measured a number of pauses at 9 seconds, this was a Saturday and by Monday at noon I had a pace maker. While being prepped for the surgery I had a pause that was 18 seconds long so I guess we caught it just in time! That was July 19th 2023 and since that day I have not had 1 pause. The pacemaker has done its job and has been pacing 82% of the time.
I still walk 4 km a day and dig in my garden so life has not changed in that respect.
I am waiting for an ablation in the next 3 or so months.
Calvin

I also had long pauses, but I feel it was caused by the metoprolol. In my case, I had gone for almost three years on 12.5mg/BID. Then, my AF seemed to become more aggressive, and before long I was taking 100mg per day. I had a first ablation, but ended up in the local ER six days later feeling distinctly unwell, and in AF detected by my own GP when I went in per instructions upon release from the cath lab. I drove myself to the ER, they EKG'd me right away, and the orderly offered to walk me down to Emerg. When there, my heart would stop for long periods, causing the nurse to rush into my ward. Long story short, I was put on Amiodarone and told to cease metoprolol immediately...cold.

I can sympathize with your being dismayed at what must sound like a pretty darned drastic measure....a pacemaker of all things! It won't help, but I was worried, when my first ablation failed, that maybe that is where I would end up. When I tried to think about it logically, I understood that literally millions across the globe live perfectly normal everyday lives under the good graces of this technology, which has only gotten better with time. And, a pacemaker beats pretty much any other hand you can be dealt if you can't be mechanically repaired via ablation.

I don't know how much you know about ablations. They have a pretty decent success rate, certainly the second or third time if that is what it takes. I've had two, seven months apart, and celebrated a year free of AF mid-February. But, while they tell you to take it easy the first week, that's only for heavy lifting, calisthenics, that type of thing. No hot tub for a week. But really, you can pretty much do anything else. Also, there's an 10 week blanking period, give or take, during which your heart calms itself ands gets used to being in NSR again. After the blanking period comes the formal assessment, and that is when you're issued a Holter monitor or equivalent, often just over night. If it's clear of PACs and AF, you're sent a digital thumb up and you go on living.

Thank you for your reply Gloaming.
Did you wind up getting a pacemaker? It sounds like getting off the Metoprolol got rid of your pauses?

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gloaming
I also had long pauses, but I feel it was caused by the metoprolol. In my case, I had gone for almost three years on 12.5mg/BID. Then, my AF seemed to become more aggressive, and before long I was taking 100mg per day. I had a first ablation, but ended up in the local ER six days later feeling distinctly unwell, and in AF detected by my own GP when I went in per instructions upon release from the cath lab. I drove myself to the ER, they EKG'd me right away, and the orderly offered to walk me down to Emerg. When there, my heart would stop for long periods, causing the nurse to rush into my ward. Long story short, I was put on Amiodarone and told to cease metoprolol immediately...cold.

I can sympathize with your being dismayed at what must sound like a pretty darned drastic measure....a pacemaker of all things! It won't help, but I was worried, when my first ablation failed, that maybe that is where I would end up. When I tried to think about it logically, I understood that literally millions across the globe live perfectly normal everyday lives under the good graces of this technology, which has only gotten better with time. And, a pacemaker beats pretty much any other hand you can be dealt if you can't be mechanically repaired via ablation.

I don't know how much you know about ablations. They have a pretty decent success rate, certainly the second or third time if that is what it takes. I've had two, seven months apart, and celebrated a year free of AF mid-February. But, while they tell you to take it easy the first week, that's only for heavy lifting, calisthenics, that type of thing. No hot tub for a week. But really, you can pretty much do anything else. Also, there's an 10 week blanking period, give or take, during which your heart calms itself ands gets used to being in NSR again. After the blanking period comes the formal assessment, and that is when you're issued a Holter monitor or equivalent, often just over night. If it's clear of PACs and AF, you're sent a digital thumb up and you go on living.

Did you stop the amiodarone after the ablations? After my pacemaker I was put on amiodarone and was on it for 4 months, it was the most terrible drug I have ever had!! I had every side effect it can produce.

Thank you for sharing your story Calvin.
How did you do on the sotolol?

I was getting pauses and sick sinus syndrome several years before I had a successful ablation. Getting the pacemaker was a relief but my Afib/flutter still progressed and after failing 2 antiarrythmics, the ablation was an even bigger relief.

Since the time that pauses often happen is as you go back into NSR after a run of Afib, I’d think that it would be very reasonable to wait a while after an ablation to see if you are still getting pauses—especially as your rhythm may take a few weeks to become stable after an ablation.

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Daisy
I was getting pauses and sick sinus syndrome several years before I had a successful ablation. Getting the pacemaker was a relief but my Afib/flutter still progressed and after failing 2 antiarrythmics, the ablation was an even bigger relief.

Since the time that pauses often happen is as you go back into NSR after a run of Afib, I’d think that it would be very reasonable to wait a while after an ablation to see if you are still getting pauses—especially as your rhythm may take a few weeks to become stable after an ablation.

Daisy
You are absolutely right about the pauses happening right before you go back into NSR. It was a feeling I embraced and looked forward to because the what I called black outs meant Id be back in NSR again. Seems crazy to say I looked forward to the pauses but they did mean Id be back in NSR.I looked forward to the pauses until...........I started to fall down during a long pause, lucky most were at night and I fell against the bed. I did have 2 pauses during the day and both were when riding my motorcycle, it was lucky I was on a straight stretch!!! That is what caused me to go to the ER and the rest is history. My pace maker is now 8 months old and I don't even think about it 90% of the time.

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Evelyn
Thank you for sharing your story Calvin.
How did you do on the sotolol?

I am still on the Sotolol and I am doing OK I am in NSR 94% of the time and 6% in flutter or A Fib. The cool thing about the pace maker is they can read it and tell you the % of time you are not in Rhythm. They also read the battery life and at my 3 month checkup my battery had 13 more years of life.

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calvin
The cool thing about the pace maker is they can read it and tell you the % of time you are not in Rhythm. They also read the battery life and at my 3 month checkup my battery had 13 more years of life.

And you don’t have to have heart monitors stuck to your chest anymore (unless you are in a hospital telemetry unit where they need to see it in real time). I get a 16 page readout sent to me about every couple of months as part of my monitoring. And if you do go into Afib, a clever EP or pacemaker tech can often convert you by manipulating your pacemaker for a minute or so.

To answer both sets of questions, no, I was fortunate to have an EP who is excellent and who was interested in having another crack at my arrythmia. He won the second round with a KO? >< No pacemaker.

And yes, as many here will attest, Carey being one, metoprolol is great for mild and early cases of AF, but later on, certainly once the heart is being fiddled with, or when the dose of metoprolol climbs into the 'holy cow' range, it can cause long pauses. My case was right after an ablation, but I also had recurrent AF right away. And this is where I was introduced to Amiodarone. I initially was placed on it for six weeks, but I needed another two weeks when I was back into the ER with only two days to go on my 6 week regimen of amiodarone. The ER doc shrugged and said, well, maybe you need another two weeks on the maintenance dose of 400mg (200mg BID), and then start the tapering dose of 200mg/day once again. It worked for all of four weeks and the AF started up again. By then I was in contact with the EP who arranged for another ablation.

I was dismayed when the ER doc said he'd talked to my EP and the two agreed to put me on amiodarone. I already knew what was up with that drug, which google agreed was the 'drug of last resort' when I asked that very question. Fortunately, I had no noticeable side-effects....none. I have been lucky that way. I went off it at the end of the blanking period and have never gone on it again, not even when I reverted to AF a few weeks later. I was told mo' meto', and ended up on 150mg/day. Then came the second ablation and it worked...thanks to the Big Guy.

I don’t think anyone wants a pacemaker .. just like cancer chemo or other situations when it’s out of your control and you just need it and move on.

The morning after an ablation I had a 15 second pause. I stayed until the following morning to be discharged. 3-4 days post ablation, I had pauses every 5-10 minutes in the ER because I had a 170hr and my heart was trying to restart. I was told by the ICU to make my funeral arrangements. It’s unusual and I only know one other person who experienced this.

So I had a pacemaker or it was suggested I could discharge myself . Easy choice.

It has a few pros..keeping me alive, boost therapy PM settings that many times had converted me, 24/7 accurate holter. I can always use my app (lowers your battery life so don’t do it daily) and start a manual download so my doctor remotely can read it if I have concerns and don’t want to come in for a visit. I did that a few times total when asked when I called my EP service during weekends. The PM report will list your episodes, burden and can alert your doctor if anything is out of the ordinary. My battery is around 10 years because I’m PM dependent.

If it makes you have a better quality of life..or even being alive, it’s worth it. The scar is minimal and the procedure is not long.

The few cons are one needs to wear a sling on their left arm for a couple of days and restrictions for 6 months on lifting above your head until the wire leads are scar tissue secure. And maybe be near wifi for nightly PM transmissions or use a phone app. I use an app on my phone instead of a bedside monitor so I can use data if I’m not near wifi…and lastly I prefer not to get wand security or go through the security machines although the TSA says it’s safe.