Persistent Atrial Fibrillation After Two Ablations: Causes and Solutions

Frequent recurrence of arrhythmia after radiofrequency ablation?

Hello, Doctor.
In the past two years, I have undergone two catheter ablation procedures for atrial fibrillation at the Taipei Veterans General Hospital.
After the first procedure, my symptoms did not improve, so I had a second procedure at the beginning of 2016.
Before the second ablation, I was continuously taking "Dronedarone," but it was not effective.
Two months after the second ablation, I switched to "Metoprolol," which I am still taking, one tablet in the morning and one in the evening.
Initially, Metoprolol worked very well; for a month and a half, my heart did not experience any arrhythmias or premature contractions.
However, the symptoms have since recurred.
Currently, my symptoms have not improved, and they are somewhat different from before the ablation.
Now, every evening when I lie down, I start to experience premature contractions, which occur intermittently.
Sometimes, after a series of premature contractions, my heart begins to race (alternating between fast and slow).
In the morning, when I get up, most of the symptoms disappear.
When I experience premature contractions or arrhythmias, it causes a feeling of air hunger, which is quite bothersome and uncomfortable.
I have a few questions: (1) Does experiencing premature contractions or arrhythmias generally cause a feeling of air hunger? (2) My attending physician mentioned that lying down triggers premature contractions and that it is related to the vagus nerve.
If that is the case, are there any medications for this? (3) During my two ablation procedures, my blood pressure was unstable, so the doctor said he was hesitant to increase the ablation energy.
He indicated that this might be a reason why the second ablation was not successful.
He mentioned that if I were to undergo a third procedure, it would require general anesthesia to stabilize my blood pressure for a more thorough ablation.
(4) Given my ongoing arrhythmias, is my risk of stroke significantly high? I apologize for asking so many questions, and I appreciate your help.

Ding Xiansheng, 50~59 year old female. Ask Date: 2016/09/19

Dr. He Dongjin reply Cardiology

Hello, it seems that with your ongoing arrhythmia and atrial fibrillation, the risk of stroke is quite high.
The symptoms can vary from person to person, and whether you can take medication should be discussed with your attending physician.
Essentially, your attending physician will prescribe medications that are suitable for you.
Taipei Veterans General Hospital is currently one of the leading centers for arrhythmia treatment in the world, so you can rest assured and continue your follow-up care there.
Changhua Hospital is concerned about your well-being.

Reply Date: 2016/09/19

More Info

Persistent atrial fibrillation (AF) after two ablation procedures can be a challenging situation for both patients and healthcare providers. Your experience with AF and the subsequent treatments you've undergone raises several important points that warrant discussion.

1. Understanding Early Contractions and Palpitations: It's common for patients with atrial fibrillation to experience premature atrial contractions (PACs) or other forms of palpitations. These sensations can indeed lead to discomfort, including feelings of tightness in the chest or "air hunger," which you described as "打氣膈." This sensation can occur due to the heart's irregular rhythm, which may stimulate the vagus nerve, leading to gastrointestinal symptoms or a feeling of breathlessness.
2. Vagal Influence on Heart Rhythm: Your physician's suggestion that lying down may trigger early contractions due to vagal tone is plausible. The vagus nerve plays a significant role in regulating heart rate and can influence arrhythmias. When you lie down, increased vagal tone can lead to more pronounced PACs or even AF. While there are medications that can help manage vagal tone, such as beta-blockers (like the "律博克" you are currently taking), lifestyle modifications may also be beneficial. Techniques such as deep breathing, yoga, or other relaxation methods can help manage vagal tone and potentially reduce the frequency of these episodes.

3. Challenges with Ablation Procedures: The fact that your blood pressure was unstable during the ablation procedures is a critical factor. Unstable hemodynamics can limit the effectiveness of the ablation, as the electrophysiologist may not be able to deliver energy effectively or safely. If a third ablation is being considered, it is essential to ensure that your blood pressure is well-controlled beforehand. This might involve adjustments in your medication regimen or additional monitoring to stabilize your condition.

4. Stroke Risk and Atrial Fibrillation: Regarding your concern about stroke risk, persistent atrial fibrillation does indeed increase the risk of thromboembolic events, including stroke. The risk is particularly heightened in patients with additional risk factors such as hypertension, diabetes, heart failure, or a history of stroke. It is crucial to discuss with your healthcare provider whether you should be on anticoagulation therapy, such as warfarin or direct oral anticoagulants (DOACs), to mitigate this risk. The CHA2DS2-VASc score is a commonly used tool to assess stroke risk in AF patients and can guide treatment decisions.

5. Next Steps: Given your ongoing symptoms and the complexity of your case, it may be beneficial to seek a comprehensive evaluation from a cardiologist specializing in electrophysiology. They can assess your current treatment plan, consider the possibility of a third ablation, and evaluate the need for anticoagulation therapy based on your individual risk factors.

In summary, your experience with persistent atrial fibrillation after two ablations highlights the multifaceted nature of this condition. It is essential to address both the arrhythmia itself and the associated symptoms, while also considering the risk of stroke. Open communication with your healthcare team and a thorough evaluation of your treatment options will be key in managing your condition effectively.

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