Arrhythmia and Depression

I had open heart surgery in January of this year. The surgery was to bypass blocked coronary arteries (CAB) and to remove scar tissue left from my heart attack (LVA). Another component was a modified maze procedure, to try and address my atrial fibrillation and atrial flutter. The first two procedures were a resounding success. My ejection fraction is 55, which is essentially normal. This was an improvement from an EF of 30 before the surgery. But the maze procedure completely failed to address my arrhythmias. Since June, I've been suffering increasing bouts of arrhythmia combined with tachycardia.

Since May, I've been experiencing an episode of major depression. Over the last ten days, I started skipping medication doses due to forgetfulness. I also varied the times I took the medications because my sleep patterns were disrupted.

To understate the case, these two illnesses are interacting in an unfortunate way. It's not just that my depression interferes with my medication schedule. Because of debilitating symptoms (shortness of breath, exhaustion), the arrhythmia makes the depression worse. So that's a tidy little vicious circle.

Last Monday morning, about 2AM, the arrhythmia got worse. My heart was racing at about 140 beats per minute, and I became concerned about it. I took a cab up to the local ER, where I presented myself as suffering from arrhythmia and depression. After examining me, the ER doctor made the decision to admit me into the intensive care unit for the former condition.

I spent two nights in ICU before moving to over to the Telemetry Care Unit (TCU.) I'm still sitting there as I write this. My electrophysiologist has a wealth of new data on my heart condition. That in turn has allowed her to clarify the choices I am faced with. These break down into two main choices. First, we could continue "medical management" of my condition, meaning we could try to control the arrhythmia with drugs. The drug of choice for in my case would be amiodarone. I went on this drug after my heart attack, and it controlled the arrhythmias. But then it gradually stopped working. Higher doses are possible, and we are trying those to see if we can't get the a-fib/flutter under control. The drawback of amiodarone is that it has toxic effects on the liver. Since I'm only 53, those effects would be more likely to show up if I went on the medication for the long term. Amiodarone also interacts with just about every other medication on Earth, limiting clinical choices when dealing with other conditions. Also, there's no guarantee that amiodarone will work at a higher dose.

The second option is ablation surgery. This is a technically very interesting procedure done by passing catheters up the femoral artery. Two have sensing electrodes and one an RF generator. The surgeon attempts to induce the arrhythmia, then measures electrical conductivity on the atrium looking for the rogue circuit. Once found, the RF generator is used to scar the atrium in such a way as to disrupt the circuit. Then the surgeon tries to induce the arrhythmia again and the procedure is repeated as often as needed. There are two factors that complicate this choice in my case. First, I have atrial fibrillation and atrial flutter. That means that the circuits involved are more complex, and so correspondingly more difficult to fix. The second factor is that it's likely that I have arrhythmia arising from the left atrium. To get there, the surgeon has to drill through the wall separating the two atria. This lengthens the time required for the surgery. Most critically however. It raises the chances of a stroke to 1%.

And that's where my depression comes in. If I don't keep up with my blood thinning drug, and maintain my INR within therapeutic range, the risk of stroke with a left side ablation rises to between 3% and 7%. As my electrophysiologist says, a stroke would "ruin everything" for me. So I need to be sure nothing will interfere with my dosing and testing schedule. But the depression has recently caused me to miss doses, so my electrophysiologist is insisting the depression either be resolved, or that I enter into a living situation where someone can ensure I take my meds on schedule.