AF, GERD and post op report

I am now about 4 months post operative from my Nissen fundoplication and I thought I would report my findings to this board. The results may not have been not exactly what I expected. Briefly, I am a 61-year-old pediatrician with LAF of the vagal type that started July 05. I have had about ten episodes of AF, one requiring cardioverting and the only cardiac meds I have used are PIP once (flecainide).

I noticed that I developed acid reflux (GERD) symptoms (coughing and hoarseness after meals) about three months after my first episode of AF and I also had increasing numbers of ectopic heart beats (PACs), usually at night. I also noticed that the PACs were worse if I slept flat, worse after a big meal and/or bending over after eating, and that alcohol, chocolate and tomatoes were all triggers. I started taking a PPI (proton pump inhibitor) and then went for 22 months with out AF and with many less ectopic beats.

Unfortunately after 22 months the AF returned as well as more ectopic beats at night, Not only was I having ectopic beats at night, but also strange symptoms such as if I stretched before I was fully awake I would have ectopic beats or brief runs of mild tachycardia (HR would go from 48 to 98). The moment of waking from sleep seemed to be the most vulnerable period for the onset of this cardiac irritability.

I found in the medical literature three articles (two from Europe and one from Stanford) which discussed the apparent correlation between acid reflux and atrial arrhythmias. There were also two case reports of patient having anti-reflux surgery and then showing improvement in atrial arrhythmias.

I decided to try and replicate the Stanford study in myself. I did Holter monitoring and simultaneous PH monitoring (looking for acid reflux). My plan was to perform these tests pre and post operative after the same late meal of triggers. The pre-operative testing was highly positive. After a heavy meal of pasta with tomato sauce, white wine and French bread, I went early to bed and slept with no elevation of the head of the bed. I had four episodes of PACs and four episodes of reflux all occurring in the same time period.

I then had the surgery February 26th. I awoke after surgery with my abdomen slightly distended (They had not placed the usual NG tube which helps to decompress the stomach after surgery.) Much to my dismay I had numerous PACs until the distension resolved in about 4 hours. My interpretation of the continuing PACs was that not only reflux (which I probably was no longer having because of the surgery) but also abdominal distension with stimulation of the vagal nerve could cause ectopic beats.

As the weeks went by though, I noticed that the same triggers that had caused ectopic beats in the past were still causing ectopic beats with the added problem in that I more often had mild gaseous distension as this is a common side effect of this kind of surgery. I also had two brief episodes of AF.

I then performed a PH test overnight without a Holter monitor and a third test two weeks ago with a Holter monitor. Both were performed after provocative suppers. The first test without the Holter relied on my perception of PACs (which is usually quite accurate) and the second relied on the simultaneous Holter monitoring.

The first post op test still had several episodes of PACs and this time with no reflux. The second post op test actually had no reflux and scarcely any ectopic beats. It could be interpreted as a success and possible proof of the theory that reflux caused the PACs and possibly the AF but my guess is that it was just one of those unexplainable good nights that caused the lack of PACs on this second test.

The reason I think this was not proof that aggressively treating reflux improves Afib is the topic of the rest of this post and a possible cause for some hope. When I had PACs and no reflux, I went back to examine the original pre-op study and realized that the PACs actually preceded the reflux by several seconds on two of the four almost simultaneous occurring episodes. In other words, either the PACs caused the reflux, or more likely some other event was causing them both. What is also more evident to me, now that I get this mild abdominal distension at times, is how often that condition seemed to bring on PACs. In addition, even though I no longer have reflux, the same conditions still provoke cardiac ectopy including bending over after eating, lying flat after a big meal and alcohol.

I was guessing that upward pressure on the diaphragm is the real culprit but had no further suggestions for myself or anyone else until directed by this board to an article posted 6/7/08 on “vagal nerve imbalance”. One of the suggestions in the article was to try gently pushing into the abdomen under the xyphoid process, pushing down and slightly to the left. The theory proposed is that the vagal nerve gets pinched as it goes through the diaphragm and that this manipulation could help free it. As my mechanism seems so clearly mechanical, I tried the manipulation. In my case I can often feel a slight "giving" sensation as I push in down and to the left.

I have learned to try and not get too excited after a success of only a short time and this success has only been seven days but the result has be quite remarkable. Virtually all my episodes of PACs and the brief runs of mild tachycardia have vanished. I did wake once with a few PACs and performed the manipulation again and they stopped. What is also apparent is that the mild gas bloat syndrome (which is common after a fundoplication) has also greatly decreased as if the bloating is actually partially caused by this pressure against the diaphragm.

Because I have had surgery, my stomach and its relation to the diaphragm are different then most. I am very interested to know if others whose cardiac irritability is worsened by position and gaseousness are able to get relief from this simple manipulation.

It is also possible that my surgery has helped as the gas bloat symptoms subsided and of course it can just be a good week.

I am interested in all feedback.

Hi Lee,

Jackie has written about a "diaphram adjustment" several times, and how it benefitted her. I'm not sure we're talking the same thing, but perhaps related.

<[www.afibbers.org];

And it was mentioned in CR 28:
[www.afibbers.org]

Glad it is working for you!

George

Hello Lee, somebody will surely update session 61 sooner or later and i want to be sure this post is in there. Thank you for a thorough and thought provoking report. Please do keep us posted on developments.
PeggyM

One of the suggestions in the article was to try gently pushing into the abdomen under the xyphoid process, pushing down and slightly to the left.

Lee,

I have found pressure like this to be helpful. Never thought about the pushing to the left, but as I use my right hand that does indeed occur.

I can hear/feel the gurgling as things move but am not sure whether it is stomach or intestinal.

I was checked for possible hiatus hernia some years ago and have no real reason to think things have changed.

Since elevating the head end of my bed I'm sleeping better and have [dare I say?] no nightly reflux, but I do take a small amount of gaviscon last thing as a precaution.

Many thanks for posting your update.

Joyce

Lee - I did report several times as George mentions and my focus was stimulated by the Rochlitz article on vagal imbalance. My chiropractor did the manipulations and it was impressive how rapidly I went from daily AF to none. Last year (07) and after my ablation in 03, I had four breakthrough arrhythmias.... once again I went to the DC for diaphragm adjustment. He said it was slightly elevated. Now I go back periodically to be sure it stays put.

Your self-maneuver is similar to how he adjusts my diaphragm although he uses both hands and from several aspects of pressure coupled with a breathing instruction to 'hold' and then 'release' depending on what he senses through his fingertips.

Crowding or impinging on the vagus nerve has always been considered a potential initiator. And any bloating, gas, distention or even that from Candida overgrowth could impinge on the vagus and create that irritation. I recall PC writing about the influence of baroreceptors and postural changes being involved with triggering afib... It may have been in one of the many excellent Conference Room topics he contributed.

I was bothered by a postural change - typically bending over to place my tee in the ground. In my files I found this clip...on the baroreceptor connection. (Once my diaphragm displacement was corrected, I no longer had the problem of bending from the waist and triggering AF).

Cardiopulmonary baroreceptors are also located in the pulmonary vascular junctions and in the left ventricle. In response to a change in posture, such as standing upright, gravity displaces 500 mL of blood to the abdomen and lower extremities. With a decreased venous return to the right heart, reflexes are activated.

I hope your experimenting provides you (and us) with some definitive guidance about cause and effect.

Jackie

Lee,
is it true you cannot vomit after this procedure? What happens if you get food poisoning and need to rid yourself of the food?
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Thanks for all the comments. In regards to the ability to vomit after a fundoplication. I have been told that I no longer can vomit and if I really needed to empty my stomach, they would have to put a tube down. They also said that I would not be able to pass gas up (burp) but I am able to.

I am pleased to be off the proton pump inhibitors and to no longer have coughing or hoarseness after meals. I was hoping that the surgery itself would lay a bigger role in calming down ectopic activity and I am not yet convinced that the surgery did this even though my last monitoring test was much better.