Atrial Fibrilation ablation surgery or Pacemaker

I have had two ablations and, since the second one, a fib has recurred three times. I'm 85. My EP recommends a third ablation or a pacemaker. I would appreciate opinion since, as I understand it, I will continue to have a fib and not sure what that means. Would appreciate any and all opinions and experiences.

@evelynd It is a progressive disorder for the vast majority of AF patients. It is almost certain to get worse if it is not 'checked', and the best way to do that is with an ablation. My understanding is that an ablation fails if it does not block, or corral, the re-entrants where the signal comes into the left atrium and takes over or coerces its rhythm. The reason is that there is more than one wall, of the six in a left atrium, that has these foci and the electrophysiologist (EP) has missed one or more of them and they're still freely signalling the myocardium to beat at they command it to. A third ablation might do the trick, but I would consider seeing a new EP who is known to subdue 'complex cases', which you appear to be.

My first ablation was a bust, and I had been sliding downhill quickly by the time it came about. Inside of six days I was in the local ER experiencing long pauses because the EP team had left me on 50 mg of metoprolol BID in case I had the typical breakthrough AF that often happens in the first three/four weeks after an ablation....I had RVR and my rate was always 140 plus, sometimes 180 (RVR is 'rapid ventricular response' and is indicated when one's AF rate exceeds 100-110 BPM). So the metoprolol was a prophylactic against that high rate. Turns out the pauses were caused by that same medication, so I went on amiodarone that very day, and stopped metoprolol completely...cold.

Second ablation, same gentleman EP, worked, and I am within six weeks of being AF-free for three full years. I think you can get there, but you might need a fresh approach, certainly one willing to accept that you have multiple foci that have been missed.

Note that I am not medically qualified....at all. No medical training. But I have done a lot of self-teaching on heart arrhythmia, mostly about flutter, PACs, and AF.

@gloaming

Thank you so much for that information. My EP has recommended either a third ablation or a pacemaker and ablation. The third ablation would be at a different site and I’m trying to figure out how to evaluate the pacemaker option. Since the pacemaker option doesn’t cure the a fib, then what is my life looking like Going forward? Any other suggestions comments are welcome. Thank you.

@evelynd hj

One more thing, what’s aPAC?

@evelynd Premature atrial complex, or premature atrial contractions...both appear in the literature. Take your pick. It is a quick extra atrial beat followed by a pause, and then the next beat is usually/often a real thumper that makes you sit up and take notice. You feel it in the neck or just in the chest. They are more benign than AF, but they can be precursors to full-blown AF. For both arrhythmias, the cardiologist and EP look to the overall 'burden', or how many of them you have in a 24 hour period. If either one rises to the 8% level they begin to talk to you about an ablation or other remedy. However, I have seen literature recently that this high level of burden should be reduced to the 3% mark as at that level morbidity rises sharply for most patients. This is a topic you can explore on your own and confront your cardiologist about if it gets in your way of decent quality of life.

@evelynd You won't die from AF. You might find it miserable, but if they can reduce the incidence of AF somehow, pacemaker or drugs, or another ablation, you will feel better. Discuss this with a good and popular electrophysiologist. There is almost certainly some relief for you.

@gloaming thanks