Andrew Cordek Mount Carmel College of Nursing Gerontology

Atrioventricular Junction Ablation with a Bi-Ventricular Pacemaker Insertion vs. Continuous Cardioversion and Anti-arrhythmic Medications

Indications for atrioventricular junction (AVJ) ablation and Bi-ventricular (Bi-V) pacemaker insertion vs. continuous cardioversion and anti-arrhythmic medications Drug-refractory atrial fibrillation with symptoms resulting from a rapid ventricular rate Drug-refractory asymptomatic atrial fibrillation with a rapid ventricular rate causing tachycardia cardiomyopathy ICD recipients with inappropriate shocks for atrial fibrillation with a rapid ventricular rate Heart failure patients with biventricular pacing inhibited by rapidly conducted atrial fibrillation Patients with symptomatic atrial fibrillation with a rapid ventricular rate that have a separate bradycardia

The leading cause of death in the Older Age adult population is heart disease secondary to heart failure. A large portion of patients with heart failure have atrial fibrillation (A-Fib), along with tachycardia, and cardiomyopathy that develops into Left Ventricular impairment, as they are unaware of their arrhythmia and the rapid ventricular rate. They only notice symptoms once the cardiomyopathy has developed. Initial treatment is the restoration and maintenance of sinus rhythm with two methods: 1. cardioversion and anti-arrhythmic drug therapy 2. Atria Ventricular Junctional ablation (AVJ ablation) with a right ventricular (RV) or biventricular (Bi-V) pacemaker Cardioversion: Can be used to treat many types of fast and/or irregular heart rhythms. Most often, it is used to treat A-Fib or atrial flutter. But cardioversion may also be used to treat ventricular tachycardia, another arrhythmia that can lead to a dangerous condition called ventricular fibrillation (which can cause cardiac death). During cardioversion, your heart and blood pressure are monitored and a short-acting sedative is given. Then an electrical shock is delivered to your chest wall through paddles or patches that stops the abnormal heartbeat and allows your heart to resume a normal rhythm.

Andrew Cordek Mount Carmel College of Nursing Gerontology The Health Care Professional will want to give you blood thinners pre and post procedure. In some people, a moderately invasive imaging test called transesophageal echocardiogram (TEE) may be performed prior to the cardioversion to make sure that the heart is free from blood clots. The TEE is performed by swallowing a narrow tube with a camera at its tip that can be placed against the back wall of the heart. Internal cardioversion may be used in people whose heartbeat did not return to normal after external cardioversion. Internal cardioversion works by delivering an electrical shock through soft wires (catheters) placed in the heart. Because the patient is sedated, the shock isn't felt. A successful cardioversion may take several electrical shocks. This can be very uncomfortable for the older adult client and the increase amount of stress in this situation can make the symptoms worse.

What's the Difference Between Cardioversion and Defibrillation? Cardioversion and defibrillation procedures both use a device to deliver an electrical shock to the heart. Electrical cardioversion, however, uses much lower electricity levels to give the shock than defibrillation. Defibrillation is often used to treat much more difficult to convert arrhythmias. Various studies have reported that electrical cardioversion is over 90 percent effective in converting to a normal sinus rhythm ALTHOUGH MANY PEOPLE CONVERT BACK TO A-FIB SHORTLY AFTER. Success has been shown to be enhanced when patients are on an antiarrhythmic drug beforehand, which helps prevent reverting back to afib. This causes the patient though to still be on anti-arrythmic medications that are only creating adverse effects such as: 1. orthostatic hypotension, which has lead to serious falls in the elderly and further arrhythmic heart patterns 2. Liver toxicities, due to the decrease metabolism rate. 3. Renal toxicity due to the increase in concentration of the medications in the organ system and the dehydration from medications like Lasix, which can lead to renal failure.

Success depends on the size of the left atrium as well as how long the patient has been in A-Fib. Most patients who have A-Fib are diagnosed within two years of already having the arrhythmia pattern or the patients have a very large left atrium (greater than 5 cm)will find that electrical cardioversion is not effective in converting to or maintaining a normal sinus rhythm then. Following a successful electrical cardioversion, the goal is to maintain a normal sinus rhythm, which only happens with about 2030% of patients within the first year if they are not on antiarrhythmic drugs for rhythm control.

Andrew Cordek Mount Carmel College of Nursing Gerontology While medications and electrical cardioversion are common for atrial fibrillation treatment, THEY DONT CURE A-FIB! Having a stroke is the most serious risk. Cardioversion may dislodge a blood clot in your heart. Cardioversion also has other risks: 1. You can get a small area of burn on your skin where the paddles are placed. 2. Amioderon is a very common drug given after getting a carioversion. a. May cause lung damage that can be serious or life-threatening. b. Lung disease while taking amiodarone. Fever, shortness of breath, wheezing, other breathing problems, cough, or coughing or spitting up blood are serious symptoms. c. Liver damage. Symptoms for liver damage may include: nausea, vomiting, dark colored urine, excessive tiredness, yellowing of the skin or eyes, itching, or pain in the upper right part of the stomach. d. You could possibly be hospitalized for one week or longer when you begin your treatment with amiodarone. e. Your doctor will monitor you carefully during this time and for as long as you continue to take amiodarone. f. Your doctor will probably start you on a high dose of amiodarone and gradually decrease your dose as the medication begins to work. g. Your doctor may decrease your dose during your treatment if you develop side effects. h. Your doctor will order certain tests, such as blood tests, X-rays, and electrocardiograms (EKGs, tests that record the electrical activity of the heart) before and during your treatment to be sure that it is safe for you to take amiodarone and to check your body's response to the medication 3. You could have a reaction to the sedative given to you before the procedure. But harmful reactions are rare. 4. The procedure may not even work. You may need more cardioversion or the internal cardioversion. The only clinical scenarios where it may be a useful intervention for cardioversion is: 1. Patients presenting acutely, within 24 hours of onset 2. Patients who are very symptomatic despite medical therapy. Even in these instances, oral anticoagulation should be considered long term because of the high rate of recurrence

Andrew Cordek Mount Carmel College of Nursing Gerontology AVJ ablation with a RV or Bi-V pacemaker Method: When AVJ ablation is performed by inserting a temporary trans-venous right ventricle pacing wire in the patients femoral vein, which will go up through the inferior vena cava, through the right atrium, and into the right ventricle in order to create an electrical signal to the AV junction node to create a normal sinus rhythm. The permanent pacemaker is typically implanted immediately following the AV junction ablation to minimize the period of temporary pacing from the femoral route. Dual-chamber pacing allows AV synchrony during sinus rhythm and physiological changes in heart rate determined by sinus node activity.

AVJ Ablation procedure:

Andrew Cordek Mount Carmel College of Nursing Gerontology

Patients with permanent atrial fibrillation who undergo AVJ ablation can have their ratecontrolling medications stopped unless they are required for other indications such as angina, heart failure, or hypertension. Patients with paroxysmal atrial fibrillation have the option of stopping anti-arrhythmic or continuing them with the aim of reducing atrial fibrillation burden. Many patients will be undergoing AV junction ablation because of two main reasons: 1. Older adults cannot tolerate anti-arrhythmic drug therapy however, a proportion will be doing so as drug therapy has been partially effective, but not enough to provide satisfactory rhythm control. 2. Conducted multiple cardioversions that were unsuccessful There is no evidence to suggest that ongoing anti-arrhythmic therapy in patients with paroxysmal atrial fibrillation will reduce the risk. The lack of clinical benefit and the risk of potential harm would therefore suggest that anti-arrhythmic medication should be stopped after AV junction ablation in most individuals. Patients with impaired LV function at baseline who underwent biventricular pacing showed the greatest improvement since this would help reduce left ventricular hypertrophy and create a simultaneous rate with both ventricles. This would increase cardiac output significantly, increase ejection fraction percentage, and reduce or even cure A-Fib. With unsuccessful medication regimen for A-Fib, The method of an AVJ ablation with a Bi-V pacemaker can improve the patients overall ventricular rate control WIthdrawal of rate-controlling drugs may also improve quality of life by removing the negative anti arrhythmic drug side effects.

Andrew Cordek Mount Carmel College of Nursing Gerontology Ventricular rate may also play a part, potentially even offering symptomatic and hemodynamic improvement in patients with ventricular rates that lie within the normal range. This shows that an AVJ ablation with a Bi-V pacemaker can offer a greater improvement in left ventricular performance and at least prevent deterioration, in heart failure patients.