Friday, October 22, 2010

Cardiac Ablation

This has been a difficult and overwhelming week. Daniel's oldest brother,Adam, had a cardiac ablation as an inpatient this week. Normally, for the sake of anyone to have such a procedure, I would stay factual in my description of it and say little more, but this was difficult.
Ablation is a procedure in which a patient, who could be young, experiences a periodic disturbance in heart rhythm. Sometimes, these heart rhythm disturbances are life threatening in some people, for others, they are not but they do result in impaired pump function and the person feeling less than well. For some, medications are adequate as a means to control, but some people, require the ablation or burning of certain nerve groups inside their hearts, which trigger a competitive rhythm. Catheters are placed in the groin on both sides, and are threaded up and into the heart, and also some through a vein in the chest. The conduction system of the heart, both the healthy system, and the extra competitive system is mapped. Often, the unhealthy rhythm is induced through the use of intravenous medications. When the competitive system is identified, that particular nerve or nerve group is ablated or burned with something which is a lot like a cautery. Scar tissue forms and theoretically at least, the area is far less capable or prone to producing a competitive rhythm in future. For some this can be a lifesaving procedure, but for Adam, this corrects an intermittent problem and may help him to be healthier and more productive in the long term. Intermittent atrial fibrillation, as Adam has, weakens the heart and shortens life through both abnormal cardiac adaptation over time, or by potential for stroke. Originally, before Daniel died, Adam's issue was considered to be fairly benign and was handled by medication. However, after Daniel died unexpectedly and without demonstrable cause, cardiologists took a new look at Adam's management and decisions concerning his rhythm issue. They were no longer quite so comfortable treating with medication alone, and felt intervention was more prudent. My father endured thirty years of non-correctable atrial fibrillation which gradually caused cardiac changes which ultimately took his life.
Other than the information above, we weren't given a great deal more information as to what the experience was like. This was largely I think, because if we had known, we wouldn't have proceeded. In preparation, there was a physical, an MRI with injected dye, and coagulation (blood clotting) studies. Then we arrived early in the morning for the procedure. It took a couple of hours to place the catheters and then the mapping began. Adam is said to have been medicated with Fentanyl and Versed during that time. Once the area responsible for the episodic atrial fibrillation was identified, a fairly large region, an area within an antrum in the back of Adam's heart in the vicinity of the pulmonary veins was ablated.(Yes, Adam has a slightly different cardiac configuration than most people.) Most people I have talked to since, had an easier course, but then, they had less surface area ablated. Some patients have their problem resolved with one ablation, and still others return a second time for the procedure, with improved results a second time.
Adam woke up in the hospital later that night unable to breathe and in excruciating pain from his chest. A cardiologist came in,did a chest x-ray on the unit, and a echocardiogram,and it was determined from listening to an audible rub with stethoscope, that he had developed a pericarditis from the procedure itself. This apparently can occur 25% of the time, and most often in males. Injectable non-steroidal anti-inflammatories were ineffective, and intravenous morphine was ultimately used to contain his pain. This was probably due to the ablation of a larger area than is done in most people, and was required in order to diminish the frequency of Adam's arrhythmia in the future.
Adam was in much worse shape than we were prepared for, prior to this procedure. In all honesty, for the possibility of an arrhythmia less often, I am not sure he would have signed on for what he experienced. He continues to recover but with a higher blood pressure and higher pulse than was anticipated. This is felt to be a result of his pericarditis.
At one juncture that evening, at about 2 am, while Adam was in severe pain, and there was some question as to whether the nurse would be waking up the physician, I wondered if I would lose Adam also.
In addition, we were not told that after he came home, he would continue to receive some injectable anticoagulants and that he would receive continuing coumadin for three months to prevent blood clots. He will also have to have periodic bloodwork during this period. It is possible that in the future we will be happier about this procedure, but for the moment, it was quite difficult, and we have the medical equivalent of "Buyer's Remorse".
The evening after the procedure when Adam was in such pain, I imagined Daniel saying to me....."Mom, I would prefer to have died than to have to have gone through this myself !" Since Daniel at 12 had less of a tolerance than Adam, this may well have been true.


 Important update to this post:

 Many people are helped by this procedure, but a percentage of them do need to have an ablation done again. Adam has experienced a symptomatic atrial fibrillation twice in the six months which followed the procedure, which is, an improvement. In the two years which have followed, he has not experienced any atrial fibrillation.
                               In addition, it should be said that some patients who require an ablation for atrial fibrillation require something called a PVI or pulmonary vein isolation.  A PVI is generally a shorter and less difficult procedure than the "cadillac of ablations" which Adam apparently truly required.

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