Would you recommend sotolal increase for frequent PVC's (>30%) or ablation?

[mmfhaley]

I was diagnosed with intermediate uveitis related to sarcoid and scans showed granulomas in the lungs in 2016.  The diagnosis was sarcoid and I was placed on cellcept.  Subsequently it was detected that I had developed frequent PVC's - greater than 40,000 per day recorded on holter monitor.  After efforts with beta blockers including flecainide and no reduction (MRI and PET CT that could not confirm cardiac sarcoid)_ I had an ablation. (PVC's were at 50% by then)  PVC's reduced to almost zero but within 6 months were back up to 10%.  In the meantime I moved and had to establish new physicians.  (all specialist doctors were and are at medical school centers) The new EP (also a sarcoid expert) believed it was sarcoid and placed recorder for heart.  After reviewing results for several months, recommended placing on sotolol and implantation of defibrillator/pacemaker to reduce risk of cardiac arrest because of nonsustained VT.  This was done in Feb 2019.  Complications occurred - (wire perforation causing pericardial effusion and cardiac tamponade).  Recovery has been slow but  PVC's have also increased again and are approaching 30%.  Because of risk of heart muscle weakening over time with such high levels of PVC's, it is recommended that I consider increasing sotolol or consider another ablation.  Since wire penetration is also a risk with ablation - I am somewhat nervous about another procedure.  The doctor is not confident that the sotolol will reduce the PVC's.  I am aware somewhat of the PVC's but it does not send me to the ER,  the shortness of breadth that seems to occur and elevations and stairs becoming more difficult is the biggest side effect.  I do walk a fair amount but have not recovered to level before defibrillator implantation.  

[2210485]

Dear God, sorry they perfed! What a crappy circumstance! Unfortunately, if a dilated condition like Sarcoid is implicated the risk for this is somewhat higher on account of the thinner ventricular walls. Some evidence suggests that guiding implants with Electroanatomic Voltage mapping helps, but this is expensive and not really common in actual practice.

Thankfully, perforation is much less likely during an ablation than an ICD implant. ICD lead wires are literally sharp metallic screws designed to cut into your heart muscle. Ablation catheters are flexible/ bendy plastic straws. Not nearly as many sharp bits to poke and prod around. Theyre designed to go into very sensitive anatomy, so I wouldn't worry as much there! It can happen, particularly when delivering energy, but I'd say you probably got much better odds regardless.

I presume you have the Defibrillator now? If so, yes, you can benefit from an additional ablation moreso than Sotalol in my opinion. The Ablation will also be somewhat more effective in reducing ICD therapies and slowing the progression of the disease. However, after a perf one can understand why you would have anxiety regarding the procedure. Ultimately the decision is yours to make.

Unfortunately, the most effective drug at reducing PVC burden is arguably flecainide. If you failed that already I wouldn't get your hopes up too much about Sotalol. The mechanism is certainly much different, so it may still work but its a real shot in the dark to be honest.

[MichelleP_3811]

I’m sorry that you haven’t gotten any responses. Your case seems complicated and that could be why. I don’t personally have a history of a high load of pvcs so my experience in the area is limited. My personal opinion for myself is to try and do the least invasive avenues first and only proceed when simple options have been exhausted. I can understand your worry about cardiac arrest especially if a doctor is concerned. They don’t usually express concern in that area unless there is a true concern but can also understand your apprehension about another ablation given the dangers. You state you have  nonsustained vt. How long does it last?  Do you feel like you will pass out when you have it?  You already have a defibrillator implanted so that may protect you from cardiac arrest. That is it’s msin job. So I guess the question becomes what does your gut say?  Our gut is usually our best bet despite others advice. Maybe consider seeking a second opinion before risking a second ablation.

I’m not totally sure but read somewhere that premature beats may have something to do with our C02 levels. Maybe if your sarcoid goes into remission the pvcs will ease up for you. Well I wish you the best whatever you decide and hope things improve for you. Take care and keep us posted on how you are