Transcript of Afib Chat with Cleveland Clinic Atrial Fibrillation Experts on October 28, 2011

November 10, 2011

  • Summary: Here is the transcript of our October 28 afib community chat with the atrial fibrillation experts at the Cleveland Clinic, which provided a rare opportunity to get answers to the most pressing questions of the afib community. There were too many questions to answer during the chat, but the doctors generously took the time to answer as many as possible in the transcript below, which is sorted by topic area. They are trying to answer them all, and we will post them when available.
  • Transcript is reprinted with the permission of the Cleveland Clinic.
  • Reading time: Approximately 10-15 minutes

Chat Description:

Atrial fibrillation is the most common heart rhythm abnormality. While it is often a mere annoyance, it is a common cause of stroke and can also be responsible for life-threatening medical emergencies that result in cardiac arrest and sudden death. Read questions and answers about atrial fibrillation from Cleveland Clinic atrial fibrillation specialists.

CHAT TRANSCRIPT:

Cleveland_Clinic_Host: Welcome to our “Atrial Fibrillation” online health chat with David Van Wagoner, PhD, Walid Saliba, MD and Mellanie True Hills, CEO and Founder of StopAfib.org. They will be answering a variety of questions on the topic. We are very excited to have them here today!

Atrial Fibrillation

LanceS:I have some understanding of “remodeling” as it relates to atrial fibrillation but I’d like to know if it can work in reverse……..if I have no episodes of AF over a long period of time (say 2 years) because I am being successfully treated with Rythmol SR, will the heart’s electrical problem remodel back to a more normal pattern? Also, I understand that the anti-arrhythmia drugs lose the effectiveness over time………is this due to “remodeling” where the disturbances find new pathways to permanently bypass the positive effects of the drugs?

Dr__David_Van_Wagoner: The atrial remodeling is strongly related to duration of afib and aging and unfortunately treatment of afib is not very effective in promoting reverse structural remodeling although the electrical changes may reverse. This means antiarrhythmic drugs are not very effective in reducing the risk of afib. There are other types of drugs that are being evaluated to prevent atrial fibrosis that may prove to have future benefits.

F94jL63:What is the relationship between PACs, SVTs, PVCs, and other “normal” arrhythmias to Atrial Fibrillation and Atrial Flutter? Doe Atrial Fibrillation predispose one to increased incidents of these other arrhythmias, and would Pulmonary Vein Ablation for A-Fib reduce/eliminate them?

Dr__David_Van_Wagoner: Premature atrial contractions (PACs) and premature ventricular contractions (PVCs) are single extra beats in the atrial and ventricular chambers of the heart, respectively. Collectively, these are considered “ectopic” electrical activity that does not originate in the sinus node (the normal origin of the heart beat). You can often perceive these as a jump in your chest. SVTs (supraventricular tachycardias) are longer episodes of rapid atrial electrical activity. PACs and SVTs may (or may not) act as triggers that can initiate episodes of atrial fibrillation or atrial flutter. As PVCs occur in the ventricular chambers of the heart, they cannot directly initiate an episode of atrial arrhythmia.

Pulmonary vein ablation seeks to isolate ectopic activity that originates in the pulmonary veins that enter the left atrium. This procedure frequently decreases the perception of PACs that originate in the left atrium, and helps to prevent the initiation and persistence of AF.

valerieR:I experience AFib, and have hypertension, and have intense stress. I cannot control my stress level mentally, and wonder what problem should be treated first. Should I take a drug for my anxiety first, to see if it will reduce the high-blood pressure and heart irregularities, or take drugs to lower blood pressure, then address the stress problem? My AFib comes and goes day and night. I am female, 56, and not over-weight. I have osteoporosis, and the only med I take is low dose estrogen. Pressure is usually above 145/90.

Dr__Walid_Saliba: Afib and stress feed into one another and need to be treated simultaneously.

Dr__David_Van_Wagoner: This was for ValerieR Hypertension also increases risk of stroke and also increases afib. So it is important to treat both. Exercise can help with stress and blood pressure reduction.

LindaR:I’ve had Afib 7 times since 12/31/10 anywhere from 1-2 mos apart and went to ER ea time to get in back in rhythm. I only take aspirin (2) 82 mg enteric everyday. Is that sufficient to keep me from getting a clot. I’ve always got back in rhythm 2-6 hrs after it starts with the help of bolus & IV diltiazem. My medicine has been changed 1 month ago to a beta blocker which seems to keep my heart rate better. Worried I should be on Coumadin. thank you………I’m 70 yrs old.

Dr__Walid_Saliba: There are other risk factors besides age that increase your risk of stroke. Should you have any of the following: Diabetes, hypertension or prior history of stroke or other vascular problems, then you need to be on a blood thinner.

Elizabeth:Does high altitude affect atrial fibrillation?

Dr__David_Van_Wagoner: At high altitudes oxygen levels are lower. This can affect metabolism in the atria and can affect neuro hormone levels that effect risks for afib. There have not been a lot of studies to systematically answer the question.

LearningCurve:What advice would you give to a young couple contemplating marriage and family when both partners have familial afib in their respective families?

Dr__Walid_Saliba: A family history of AF increases risk of AF. If one parent has AF, the risk of AF for the children is increased about 70%. If both parents have a history of AF, the risk is increased 3-5 fold. That said, AF is a condition that can be managed. Personal decisions about marriage and family involve consideration of many complex variables, with medical history only a part of this.

octofoilalum: I have had approximately a dozen instances of atrial fibrillation since a stent was placed in my right coronary artery in 2007, the first occurring four days after the stent was placed. Most lasted between 2-4 hours. One, however, in August of this year lasted over 15 hours and required ER treatment and IV treatment to correct it. On that occasion it was determined that I was dehydrated and with an electrolyte imbalance. The last incident occurred two months ago. Most of the instances occurrences when I was in bed, with my normally slow hearty rate slowed even more and when I was laying on my side. Since then I have avoided lying on my side and have had no occurrences since then. I take no medication for the “afib”. My meds are a statin and a small aspirin. Could the lying on my side serve as a “trigger” for the afib, and are there any other “triggers” that set it in motion. Thank you!

Dr__David_Van_Wagoner: In some individuals afib occurs during night when heart rate is slow. It appears you may be one of these individuals. Postural changes, eating and other activities that affect the vagal nerve can trigger afib.

Symptoms of Atrial Fibrillation

hsta:Atrial Fibrillation was discovered by the anesthesiologist in January when I was having knee replacement surgery. The doctors confirmed via EKG that indeed the condition existed. Neither before the surgery nor after have I experienced any of the usual symptoms. I had a cardioversion procedure about three weeks after the surgery and given warfarin and Multaq medications. The doctor told me I should come back in a year for a check up. Neither before the surgery or after to date have I experienced any of the usual symptoms of Atrial Fibrillation. If my heart goes out of rhythm before the year is up how will I know? Is this a serious issue?

Dr__David_Van_Wagoner: The ability to perceive AF varies tremendously from individual to individual, based in part on how much AF affects heart rate. Warfarin helps to lower stroke risk, and this is particularly important if you cannot tell when you are in AF. It is often possible to detect AF by monitoring your pulse – it is irregular when you are in AF. If you are on a therapeutic level of warfarin (which needs to be checked periodically), the risk of stroke is greatly reduced. Consult with your cardiologist about other options for detecting AF.

eddieeal:Having had an ablation that did not work, I am on schedule for an ncontact procedure. Do you have knowledge of this procedure and if so what has the success rate been?

Dr__Walid_Saliba: We do not perform this procedure here. The initial studies do not necessarily show an improved outcome compared to experienced centers.

Treatment of Atrial Fibrillation

MichaelS:I’ve been diagnosed with paroxysmal a-fib with about two episodes per year over the last six years. How long should I wait to go to the emergency room? I usually convert within 90 minutes to 12 hours of onset and do not go to the ER. My concern with the ER is unnecessary testing for blood clots, etc. which seems to be the local ER’s protocol. Past tests have shown no structural issues with the heart.

Dr__Walid_Saliba: As long as you are feeling well you do not need to go to the ER, however, if you are not on blood thinning medication then it is advisable to seek medical attention within 48hrs from onset of afib to be able to perform cardioversion without the need for TEE

SharonV:If you have Atrial Fibrillation …Please tell me what could happen if you choose to NOT to have a Cardioversion? Thank you, Thank you, Thank you! Sharon

Dr__Walid_Saliba: You need to make sure your heart rate is controlled and you have adequate thinning of your blood depending on your risk factors of stroke.

Sailor:Is there anything unique about familial (genetic) A-Fib that influences treatment options? Is heart tissue in familial A-Fib unique (more fibrous?) and therefore more difficult to treat with ablation or other surgical procedure designed to restore NSR?

Dr__David_Van_Wagoner: We are participating in ongoing studies to evaluate the genetic determinants of AF. While a few single gene causes of AF have been identified, it has become clear that these affect relatively few people. While this is the long term goal, genetic studies have not yielded information that can be used to target the treatment for individual patients. It is likely that most individuals with AF have several genetic variations that are associated with increased AF risk. However, the contribution of each of these is relatively small, and the genetic variations add to/modify the other clinical and environmental factors that affect AF risk.

A recent review can be found at: http://www.ncbi.nlm.nih.gov/pubmed/20551423

Peaches28:I’m 83 – Had Afib ’03 + “11. Metoprolol brought heart back. 2 siblings-drop over heart. I have not been put on a monitor or given blood thinner meds – only 2 baby aspirins a day. Have had blood clogs in left leg twice (’79 + ’11) following surgery on leg. Should I ask my Cardiologist WHY I’m not on blood thinners and have not had a monitor? I see him again 11/22/11? Thank you

Dr__David_Van_Wagoner: A consult with a cardiac electrophysiologist may be helpful.

Mellanie:When is rate control better, and when is rhythm control better, and what are the risks with each strategy?

Dr__Walid_Saliba: Rhythm control is advocated if you have symptoms despite rate control or if you are a young patient or are intolerant of medications taken for rate control. Most people continue to have symptoms despite rate control and feel significantly better when in normal rhythm. Unfortunately, antiarrhythmic medications to maintain rhythm control have side effects and have limited efficacy. This is where an ablation might offer an additional potential for rhythm control with still limited success and some risks.

Sailor:Does the length of time one is in constant A-Fib influence or limit the success of cardioversion, ablation, or other treatment(s) designed to re-establish NSR?

Dr__David_Van_Wagoner: Yes, both clinical observations and experimental studies have shown that atrial fibrillation episodes tend to become progressively longer-lasting. AF frequently starts with short bouts that stop and start on their own. With increasing age and longer exposure to AF, subsequent episodes become easier to induce, and tend to last longer. Thus, individuals with persistent AF are often more likely to experience AF recurrence after cardioversion or ablation than those with paroxysmal AF.

sammytig1:I do not know whether to do drug treatment or catheter ablation? I have been on medication for about one month. Age 66,no other heart problems. Is ablation worth the risk? Can a heart return to normal with drug therapy only? Can diet, rest, and weight loss help? thanks!

Dr__Walid_Saliba: If medication is keeping you in normal rhythm it is reasonable to continue such therapy. I would consider ablation if you become intolerant or non-responsive to the medication. Yes, ablation is worth the risk.

Dr__David_Van_Wagoner: Drug therapy and lifestyle changes generally do not cure afib, but these interventions can decrease the frequency of afib and the risk of cardiovascular disease.

Treatment: Medications

PatrickS:Can you tell me about the risks of long term daily use of Propafenone? I currently take a 300mg tablet in the morning and 300mg’s in the evening and it keep me out of Afib for months. Without the Propafenone I go into Afib after only a few days. I am taking the immediate release after finding the extended release ineffective

Dr__Walid_Saliba: There is always an ongoing risk of malignant arrhythmias with any antiarrhythmic medications. The risk with propafenone is small provided you don’t have underlying heart disease.

JimC:Does the medication Multaq play any part in the treatment of afib? With so many negative articles lately concerning the drug Multaq, do you have any reservation about its use?

Dr__Walid_Saliba: Yes it is an anti-arrhythmic medications. It is not one of the strongest medications available for afib. We avoid it in patients with heart failure.

MikeMc:1) What is the efficacy of ACE inhibitors (especially lisinopril) in helping prevent reoccurrence of atrial fibrillation following pulmonary vein isolation for paroxysmal AF? 2) In light of the recent study by Olsen and Lip (2011), should the current guidelines of allowing aspirin-only therapy to help prevent stroke in CHADS 1 patients be ramped up to anticoagulants?

Dr__David_Van_Wagoner: 1)The ace inhibitors are not indicated to prevent afib however some smaller studies have shown some modest effect on prevention. 2)Olson’s study needs further validation in larger clinical trials, but the comment is appreciated.

tgk:developed AF this summer……no heart or blockage problems………have pacemaker set at 60,and taking 120mg sotalol twice a day…….having asymptomatic AF as indicated but pacemaker interrogation—–in a 30 day period about 20,with duration of a few hours to minutes and max heart rate about 100……would you recommend a replacement for sotalol considering the fact that I had cirrhosis of the liver(compensated) since 1996?…..thanks

Dr__Walid_Saliba: Sotalol is excreted by the kidneys and is a good medication in your situation. however, it might not result in satisfactory control of your afib. Further follow-up is needed to evaluate the burden of afib while on this medication.

Treatment: Anticoagulation

LenD:I have been diagnosed with Atrial Fib….and advised by Veterans Admin to go on Coumadin because I have a Chad2 score of 3….one being age (over 80) and two because I had TIA several years ago on my record. BUT…that TIA was caused by carotid artery blockage and was corrected by endarterectomy. Doesn’t that, in effect, remove #2 (the 2nd risk factor) Shouldn’t my score be one instead of three? P.S. I’m currently on Amiodorene. I’m not a fan of Coumadin and won’t take it….Hopefully, the V.A. will soon approve Pradaxa

Dr__Walid_Saliba: In either situation I would advocate anticoagulation in your situation. If you don’t like Coumadin, the newer medications are a good choice. There is also the possibility down the road of left atrial appendage occlusion devices (now in research) which will preclude taking anticoagulation.

lusu222: I had a single episode of a-fib 6 months ago. I was put on blood thinners at the time. My cardiologist feels I will have to be on them for life because of the chance of another a-fib occurrence. Questions: First: is there a chance/way I can get off blood thinners as I am having severe side effects of both pradaxa and coumadin? As I said, my cardiologist thinks I will have to be on them for life because of the chance of another a fib episode. Second, I understand there are monitoring devices that can be used to check heart rhythms that are then reported to your doctor so you don’t have to take blood thinners since the heart rate is being constantly monitored. What can you tell me about these? Third, I have had intestinal side effects from pradaxa and with the coumadin, extreme hair loss. I am at a loss as to which blood thinner to take and would appreciate your input.

Dr__David_Van_Wagoner: Factors that contribute to the need for anticoagulation include age, presence of other risk factors (hypertension, diabetes, heart failure, history of stroke), and the burden of AF. In consultation with your cardiologist (or an electrophysiologist), you can determine the risk for stroke, and the most appropriate anticoagulant. A consultation with an electrophysiologist is your best way to make an informed decision about this issue.

lusu222:I AM EXPERIENCING AN INORDINATE AMOUNT OF HAIR LOSS AND FATIGUE. COULD THAT BE RELATED TO THE COUMADIN I AM TAKING FOR A-FIB?

Dr__Walid_Saliba: Yes for hair loss and no for fatigue, but afib could be causing the fatigue.

Altitude30K: I have been diagnosed with Atrial Fib. and advised to go on Coumadin because I have a Chad2 score of 3. One is for age…over 80 and 2 is because I had a TIA several years ago. BUT….that TIA was caused by blocked carotid artery and was corrected by an endarterectomy. Shouldn’t my Chad2 score really be one instead of three. I am a V.A. patient and they want to put me on Coumadin. I’m on Amioderone. I’m not a fan of Coumadin

Dr__David_Van_Wagoner: Consult with your cardiologist/electrophysiologist about the new alternatives to Coumadin. With an age over 80, it is important to maintain adequate anticoagulation status. Depending on your renal function, dabigatran (Pradaxa) may be a good alternative.

ladydi:Are they working on an antidote for the blood thinner Pradaxa?

Dr__Walid_Saliba: Yes, but it is not available yet.

dotinal: I am a 67 yr old female who experienced my first and only episode of afib last January. I was hospitalized for cardioversion and follow-up. My cardiologist prescribed Cardizem 180mg and aspirin 325mg based on a CHADS2 score of 1 (for hypertension) and a diagnosis of paroxysmal AF. Is aspirin sufficient to prevent stroke.

Dr__Walid_Saliba: With the single episode of afib and the low risk score, aspirin alone is reasonable at this point.

mikel698:what is known about the benefits and necessity of taking coumadin for paroxysmal AF, especially a case where an episode of AF lasting more than a few minutes occurs only every year or two?

Dr__David_Van_Wagoner: Chances are you have more afib that you think you do. Consult your cardiologist to determine how significant your afib burden

Treatment: Cardioversion

rguaraldo:I’ve been in AFIB for about 5wks and expect to go through a conversion in about two weeks. I understand that there is a high probability of going back into AFIB even if this conversion is successful. What if anything can you recommend to improve my chances of not falling back into AFIB.

Dr__Walid_Saliba: The use of some antiarrhythmic medication can help maintain normal rhythm after a cardioversion.

Treatment: Ablation

rreverte:I have had more than 3 ablations and I am still suffering of runs/salvos and extra beats in some cases very frequently. I think there is nothing left to be burned but the doctor told about another attempt. Can this be safe? Is there any chance that I can get cured or I have to live with this and the pills? The pills don’t work very well, I get some relief but still have the same, just less.

Dr__Walid_Saliba: From the safety standpoint, it is same risk as the first procedure. Your arrhythmia will need meticulous mapping for a successful ablation.

kth: After a pulmonary vein ablation procedure last February I suffered cardiac tamponade with acute pericarditis following for several months. I now have milder, recurring episodes of pericarditis. Could the pericarditis be triggering some AF events or does AF exacerbate the pericarditis? They seem to be related.

Dr__David_Van_Wagoner: Pericarditis is a strong trigger for Afib. And likely is an important cause of afib following cardiac surgery. Colchicine maybe helpful in controlling pericarditis. It is best to discuss with your cardiologist.

JanisM:Are there any exclusions that apply to the catheter ablation for atrial flutter, eg, age, weight, other diagnoses, etc?

Dr__Walid_Saliba: No exclusions except the weight needs to be less than 400lbs which is the operating table limitations.

Barry:At what point does it make sense to have an ablation? I have about 5-6 episodes a year each lasting on average 3 days although I have had a few that lasted a week. The risk of going into AFIB effects my lifestyle. For example, I have to avoid doing hikes that require me to camp out at a low elevation and require a climb out the next day since I don’t want to risk getting stuck in the wilderness for a few days with AFIB. Climbing several thousand feet in a day is tough if not impossible with afib. I am a vagal afibber and typically go into afib in my sleep in the middle of the night. Also I have gone into afib the night before big 20 mile hikes which have somewhat ruined parts of my vacations. Drugs do not convert me. Does it make sense to get an ablation done if it is interfering with quality of life even though I am not a persistent afibber? I know I am blessed not to have more or persistent episodes but am curious how to proceed.

Dr__Walid_Saliba: The decision to go for an ablation is up to a patient’s preference. When you have afib that starts to interfere with your quality of life and your frustration increases, then it is time to start thinking about an ablation.

Glenn:Sinus multiple times a day and even multiple times within an hour. If I have an ablation procedure, what is the likelihood that it will control my A-Fib and that I can be off Tikosyn and any similar drug completely?

Dr__Walid_Saliba: The chances of the ablation working is between 50 – 90% depending on what underlying heart disease you have.

ralphgsch: I’m 67 years old, male, 215 lbs, 6’1″ who goes to a gym 5-6 days/wk for strenuous workouts. I was diagnosed with persistent AFib in February 2011 & have been in the care of an electrophysiologist since then. A cardioversion failed in March 2011; I’ve been treated with medication since then (now carvedilol, Pradaxa, Multaq). I don’t like the side effects & am now considering catheter ablation (PVAI). (1) Am I a good candidate for PVAI? (2) What is the likelihood of success of PVAI, including the subsequent elimination of any medication? (3) If PVAI is initially successful, what is the continuing likelihood of success after 5, 10, 15 years?

Dr__Walid_Saliba: Yes, you are a good candidate for an ablation. The success rate is around 60% for persistent afib. There is on the average 3%/year recurrence rate thereafter.

Brown:Questions re ablation for a-fib: 1) Number of ablations performed in past year using: (a) RF ablation (b) cryoablation 2) Do you see outcome differences and complication rate differences between RF and cryoablation? Please explain them. 3) Which ablation strategies you use: (a) pulmonary vein isolation (PVI) (and is it circumferential) (b) substrate-based ablation using CFE/CAFE (c) hybrid combination of PVI and CFE substrate-based ablation –If more than one of these, please discuss the criteria for strategy selection 4) Mapping technique you use: manual or robotic? 5) Mfg. and model of RF catheter you use for ablation? –(and is this the one approved by FDA for atrial fibrillation ablation?) 6) Do you use irrigated catheter or non-irrigated? If both, please discuss criteria for the choice.

Dr__Walid_Saliba: 1)a. 800 ablations, b. 3 cryoablations 2) Too early to tell, but cryoablation has increased risk of phrenic nerve damage at least by studies. 3) We use pulmonary vein antrum isolation. We have both robotic modalities available, but predominately use the manual approach. And we use irrigated catheters.

BillMac:I am 52 years old and have suffered with Paroxysmal, sometimes persistent Afib for 23 years. I watched the development and evolution of the Ablation procedure during the past 20 years and finally had an Ablation performed in Bordeaux France (due to poor insurance) 4 months ago. During the procedure they told me I was rather difficult to fix but they were giving it their best shot. So far, I am much better now but still get the occasional extra beat or two during the day but nothing more. At rest, my heartbeat is much less pronounced, even non detectable and my sleeping has vastly improved. I’m now wondering if it would be worth returning to France for a second try in the pursuit of perfection. Can you please explain the main reason(s) why a second or even third ablation procedure is necessary to fix Afib, if at all. What is it that cannot be found or fixed during the original procedure that reveals itself in the repeated procedure? Does the heart muscle reconfigure the electrical pathways during the healing process?

Dr__Walid_Saliba: Recurrence of afib after an ablation is mostly due to recovery of conduction across the initially isolated pulmonary veins. Since you only had the ablation 4 mos ago, it would be wise to wait a few more months before making any major decisions.

SharonB:I have been experiencing A-fib more often but do not want to be put on anti-arrhythmic drugs. I see in Europe they have taken that out of their protocol and go from meds like coumadin and cardizem , etc, to ablation. Will that be considered here in the future due to the harmful side effects of these medications. Thank you.

Dr__Walid_Saliba: Yes, we have performed an ablation without the patient being on antiarrhythmic medications. It comes down to the patient’s preference and discussion with the physician.

GaryT:Hello, I had two ablations for A-Fib in Rochester NY approx. 3 years ago but must still take Rythmol every day to control it. My question is have there been any improvements either in the procedures themselves, or in the equipment/technology used to perform these ablations. Also, now that it has been a number of years since these techniques have been used, what is the long term/projected effectiveness of such procedures? For example; are ablations considered to be permanent solutions to A-Fib? Thank you. GT

Dr__Walid_Saliba: The ablation procedure for afib is not standardized and performed somehow differently in different centers. The long term effectiveness of this procedure is now 50% at 5 yrs in certain patients. These ablations are not permanent solutions, but part of a strategy to control the recurrence pattern of the arrhythmia.

DaleD:I am a 71 year old male with a CHADS2 score of 0 and a CHA2DS2VASC score of 1 with paroxysmal A. fib (that causes mild, tolerable symptoms). I am currently on 325 mg aspirin daily. I love to downhill ski with my son in Colorado. Could I be a candidate for catheter ablation and/or the Watchman device? And is anyone doing both of these procedures at the same time? Thank you. Can you discuss the differences between the Lariat device and the Watchman device?

Dr__Walid_Saliba: You can be a candidate for catheter ablation. The watchmen device is investigational in the US and therefore cannot be done in a simultaneous procedure (maybe in the near future).

tdjkidd:Can you have the atrial appendage clipped or removed when you have a catheter ablation?

Dr__Walid_Saliba: No, but we will have the availability of left atrial appendage occlusion device down the road if approved by the FDA

Treatment: MAZE procedure

reddog:Dear Dr. Saliba and Dr. Wagoner: I have had persistent a-fib since 2003. In the past, I’ve been prescribed Flecainide, Amiodarone, then Dronedarone, and currently back to Amiodarone, in addition to Coumadin and Atenolol. I had ablation therapy in April of 2009, and May 2011, and in both cases reverted back to a-fib. At this point, I am considering a “mini-MAZE” procedure as a means of permanently terminating the a-fib condition. I am 56 years old, a male, and in good general health with the exception of my persistent a-fib. My specific question is: What is the likelihood that a mini-MAZE procedure will be successful in a patient that has been in persistent a-fib for nearly 9 years, and in your opinion, is it a risk worth taking? Thank you very much, Tom (“red dog” is my user name)

Dr__David_Van_Wagoner: The chances are less than 50% for a mini-maze. If you would like the most effective procedure, then it would be an open-chest cut and sew Maze.

deli1999: I have had one ablation 7 months ago and after 6 months I started to have severe bouts of A-fib I am now awaiting my second procedure on Nov 17th I was told the 1st had a 75% success rate and the second would fall into the 95% success rate do you agree with the latter?

Dr__Walid_Saliba: Yes there is a good chance of better success rates with a repeat ablation procedure.

Treatment: Pacemaker

bob3rs: I have “permanent afib” – 2005 had open heart by-pass; followed w/ occasional afib(medicated) ; 2009ablation for frequent afib; 2010 diagnosed w/ “perm afib”. April 2011 “blacked-out” & broke (shattered) both leg bones when falling- metal plates &16 screws put me back together (low blood pressure – not definitive) taken off Digoxin, continued Metoprolol, 100mg daily. What should I look for the best treatment of choice? I am afraid of future “black-outs”, especially if it was related to the afib ??? I do not have any other debilitating health issues – average weight, even though I am nearly 75, I am in good physical condition.

Dr__David_Van_Wagoner: You should consult with an electrophysiologist as you may require a pacemaker.

Treatment: Hybrid Ablation

MichaelandCarol:Are you doing Hybrid Ablations? What is the hybrid procedure for atrial fib consist of and why is it not widely available?

Dr__Walid_Saliba: No we are not performing it. It consists of both the surgeon and EP do the ablation. Surgeon does it from the outside of the heart and the EP does it from the inside of the heart. It is thought to be a complete procedure however the results are not much different than a conventional ablations in experienced centers.

Valve Disease and Atrial Fibrillation

duffer50:Is there anything we can do for “ongoing” afib? Also have mitral valve regurg due to leaky valve.

Dr__David_Van_Wagoner: A leaky mitral valve increases pressures in the left atrium and can contribute to enlargement of the left atrium and changes in its electrical activity that promote AF. Surgical repair of the mitral valve may be combined with a procedure to isolate the pulmonary veins and the left atrial appendage (the Maze procedure) that will improve ventricular function and reduce the burden of AF and the risk of stroke. A consult with a surgeon who performs this type of procedure would be advised, and is available at the Cleveland Clinic.

Thyroid and Atrial Fibrillation

DorisN:What relationship do you find between a patient’s thyroid levels, especially the TSH level, and episodes of atrial fib? Do you have any specific parameters for the TSH level to be?

Dr__Walid_Saliba: Hyperthyroidism (low TSH) can be facilitated factor for afib. Parameters depend on the normal values of where the test is performed.

Atrial Fibrillation Research

elena: Although some providers state that they have a cure for AFIB, we know that presently, that is not true. What clinical trials are being done and how close(or far) are we from a cure? What form do you think a cure might take? Surgery? Meds?

Dr__Walid_Saliba: No clinical trials for a cure are currently being done. The research is being conducted to find out the triggers and mechanisms of afib. A cure for afib does not exist at this time, but rather success is measured by long term suppression of the arrhythmia.

Mellanie_True_Hills:On behalf of the atrial fibrillation community, I would like to thank Dr. Saliba and Dr. Van Wagoner, as well as the Cleveland Clinic team, for sharing their wealth of information and for taking the time to answer our afib questions today.

Dr__Walid_Saliba: Thank you for having us. This was great.

Dr__David_Van_Wagoner: This was great. Thank you again

Cleveland_Clinic_Host: We had a large amount of un-answered questions, and the doctors have generously agreed to continue answering as many of them as possible after the close of the chat. When available, the answers will be posted.

If you have additional questions, please go to http://my.clevelandclinic.org/heart/chat_with_a_heart_nurse.aspx to chat online with a heart and vascular nurse.

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Reprinted with the permission of the Cleveland Clinic.

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