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Transcript of Afib Chat with Cleveland Clinic Atrial Fibrillation Experts on June 13, 2011

Transcript of Afib Chat with Cleveland Clinic Atrial Fibrillation Experts on June 13, 2011

June 28, 2011

Summary: Here is the transcript of our June 13 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 them all in the transcript below, which is segmented by topic area.
Transcript is reprinted with the permission of the Cleveland Clinic.
Reading time: Approximately 10–15 minutes

CHAT DESCRIPTION:

The most common irregular heart rhythm disorder is called Atrial fibrillation (AF or AFib) and involves the two upper chambers (atria) of the heart. Some people may live for years with atrial fibrillation without any problems, however, it can also lead to heart failure, stroke and even death. Over 2 million Americans are affected by AFib and people with atrial fibrillation are 5 to 7 times more likely to have a stroke than the general population. Learn more about Atrial Fibrillation, including diagnosis and treatments by Dr. Bruce Lindsay, Dr. David Van Wagoner and Dr. A. Marc Gillinov from the Cleveland Clinic and Mellanie True Hills, Founder and CEO of StopAfib.org.

CHAT TRANSCRIPT:

Cleveland Clinic Host: Welcome to our “Atrial Fibrillation” online health chat with Bruce Lindsay MD, A. Marc Gillinov MD and David Van Wagoner PhD from the Cleveland Clinic, and Mellanie True Hills from StopAfib.org. They will be answering a variety of questions on the topic. We are very excited to have them all here today!

Diagnosis of Atrial Fibrillation (AF)

Mindy:I am wondering how one might tell if one has atrial fib or pvc? My husband has very brief episode of irregular heart beat for 3 seconds. He seems to notice it once or twice a day, only when sitting down. He is a generally a fit man who is 63 yrs old and golfs regularly, carrying his own bag. His brother has longer episodes and has had them since youth. My husband only has noticed these episodes for last 4 years. He has had one 15 minutes episode in his life, and several 1 minutes episodes. Doesn’t seem to change with stress, sleep, food, anything we might imagine.

Dr. Van Wagoner: AF leads to irregular activation of the heart beat. This can often be detected by checking the pulse at the wrist, but an ECG or Holter monitor during these episodes would provide the most definitive differential diagnosis of PVCs vs. AF.

Dr. Lindsay: A holter or event monitor would be beneficial—you should discuss this with your physician.

Symptoms of Atrial Fibrillation

EdNov:What symptoms should patients be looking for at home to detect that they might be in A-Fib or A-Flutter?

Dr. Lindsay: Atrial fib and atrial flutter are both associated with shortness of breath, palpitations, light-headedness and fatigue. The pulse tends to be rapid and irregular unless it is controlled by medications

DanKinn:How can I tell if I have Afib?

Dr. Lindsay: Atrial fibrillation is often associated with the sensation of a rapid or irregular heart beat. Sometimes it is accompanied by light headedness, shortness of breath or chest discomfort. An ambulatory monitor is usually needed to make the diagnosis.

EdNov: What is the range of pulse rates that patients with A-Fib present with?

Dr. Lindsay: The rate varies a great deal and can range from about 50 to 180 beats per minute.

Tru:Is having numerous PACs a form of AFib?

Dr. Lindsay: PACs are not the same as atrial fibrillation and do not necessarily lead to atrial fibrillation, but some patients they trigger atrial fibrillation. If they occur in long runs they may eventually progress to atrial fibrillation.

Dr. Van Wagoner: Atrial fibrillation (AF) is a persistent rapid, irregular electrical and mechanical activation of the atria (upper chambers of the heart). PACs (premature atrial contractions) are individual beats that might or might not initiate AF, but are distinct from AF and associated with little risk on their own.

williamsrsa:Does the AF bring on asthmatic symptoms?

Dr. Lindsay: Atrial fibrillation does not provoke asthma but it can cause shortness of breath.

Dr. Van Wagoner: Asthma is a form of airway constriction; although this also causes difficulty breathing, the two conditions are distinct, and there is no systematic evidence of AF initiating asthmatic episodes

Blinfas:I have had AF symptoms since February. Is there a possibility that it can go away with a certain time frame or am I stuck with it?

Dr. Lindsay: It is unlikely that your symptoms will resolve unless you are treated with a medication.

Dr. Van Wagoner: You should discuss your symptoms with your physician. AF episodes can start and stop on their own, or may persist for long periods of time. Appropriate treatment can help to reduce the frequency and duration of AF episodes, and the risk of stroke.

Medications for Treatment of Atrial Fibrillation

GoldieSk47:As a 64-year-old woman who had annuloplasty repair of Mitral and Tricuspid valves in Feb., 2011, and developed Afib and tachycardia post surgically which is ongoing 4 mos. after surgery, what is the most effective treatment to stop Afib and tachycardia? Anti-arrhythmic drugs, cardio version, or cardiac ablation. Cleveland Clinic performed a cardio inversion on me 4 days after surgery with success for 2 hours.

Dr. Lindsay: My recommendation would be to undergo a trial of medical therapy with another drug and repeat the cardioversion. If that is ineffective you can be evaluated for an ablation procedure.

Chowser:How long after a fib episode begins can i wait before taking an additional dose of sotalol (normally 40 mg 2x/da, so an additional 40 after a fib). Aftermath of additional dosage is unpleasant (not painful) head sensations, fatigue, weakness/dizziness, can last 4-8 hrs, would like to avoid if possible.

Dr. Lindsay: Patients should be extremely cautious about taking extra doses of antiarrhythmic medications because of the risk that they can induce a life threatening ventricular arrhythmia. You must discuss this with the physician who prescribed the drug.

fgold: Given a choice between an anti-arrhythmic drug and a cardiac ablation, if one elects to use the drug first, does he jeopardize the success of an ablation at a later date?

Dr. Lindsay: No. that is not a problem at all. It is generally considered the standard of care.

lkerry:My new EP thinks maybe my cardio misdiagnosed me…Instead of AFIB, he thinks I might have SVT. He is thinking of taking me off MULTAQ entirely and just increasing the beta blocker (metoprolol). Would that be a good approach? Will I have any issues by just dropping the Multaq cold turkey? How would they accurately diagnose me for SVT, take me off drugs completely? Thank you very much.

Dr. Lindsay: If the Electrophysiologist feels you have SVT, then metoprolol would be a more appropriate medication. The only way to resolve this issue would be to stop the multaq which is not associated with any type of withdrawal problems. The diagnosis of SVT could be established by monitoring or possibly by an electrophysiology study.

Meneldur:Hello! A pleasure being here. I’ve been diagnosed with Paroxysmal Afib 6 yrs from now. I had 3-5 episodes per year for no more than 12 hours each. Last year I started taking flecainide 150 mg/day with excellent results (no more Afib episodes so far). Can I live all my life with flecainide and no Afib? Is it common to Afib to return after a while on flecainide?

Dr. Van Wagoner: If flecainide is currently controlling your AF and you have only had transient episodes of AF, it is likely (but not guaranteed!) that it will continue to be effective. Age and other risk factors may eventually alter the balance, but flecainide can be very effective in preventing the triggers of AF.

Dr. Lindsay: It is common for anti arrhythmic medications to become ineffective over time – and in that case you can be switched to another medication or consider catheter ablation.

deannaf:I am very concerned about the dangerous side effects of PACERONE—how safe is it for AFib?

Dr. Lindsay: Pacerone is a brand name for amiodarone. Although it is one of the most effective drugs for treatment of atrial fibrillation, some patients experience dangerous side effects with long term usage. If patients are monitored carefully, these adverse effects usually can be detected before they become serious and in most cases they resolve when the drug is stopped.

FOX1933:How effective are the available medications available for AFIB?

Dr. Lindsay: The effectiveness of medical therapy for atrial fibrillation depends on whether the patient has underlying heart disease. In generally, the probability that a medication will suppress atrial fibrillation is in the range of 30–50%.

GoldieSk47:In your estimation, which antiarrhythmic drugs are effective while having the least serious side effects? What are the long term effects on the body of these drugs if used for 15-20 years?

Dr. Lindsay: Each of the antiarrhythmic medications has certain risks. I cannot say which is best because our decision about which drug to use depends on underlying heart disease, whether the patient is prone to slow or very rapid rates, kidney function, liver function, and many other factors. Amiodarone is the only drug that has cumulative toxicity over the course of years. The other drugs can cause side effects, but they do not add up over time.

millafib:I have symptomatic paroxysmal afib. I was on Amiodarone for ten years then switched to Rythmol and toprol and have been symptom free for four years. I am 62 and have no other heart disease. Rythmol is expensive. Will I have to stay on that for the rest of my life?

Dr. Lindsay: Your only options are to take this medication, another medication, or undergo ablation of the atrial fibrillation. If you are doing well on the Rhythmol, my recommendation is that you stay on it.

lrg1742:Do you recommend this “pill in the box” to bring a person out of afib?

Dr. Lindsay: The pill in the box approach is useful and safe for some but not all patients. You would need to discuss that option with your cardiologist.

MLf:I have (or probably have) a chronic, mostly asymptomatic, AF, in which rate is controlled by means of meds (diltiazem & topranolol sp?), and rhythm problems are never symptomatic enough to be bothersome, is there any reason to consider anything more “invasive” than meds (eg any ablations?). I’m not keen on long-duration medication (at age 62, I take no other meds), but I presume that the lowest-risk treatment is most appropriate?

Dr. Lindsay: Two major studies have shown good outcomes in patients with asymptomatic atrial fibrillation provided that the rate is controlled well and the patients are appropriately anticoagulated. There is no proof that ablation procedures improve survival. The main indication for an ablation is to alleviate severe symptoms. A large multi-center clinical trial is in progress to compare long term outcomes in patients who are treated with medication compared with ablation procedures.

folsomsteve:I’ve had the cardioversion, which was successful, and am currently on Warfarin, Metoprolol and Flecainide. . . should I expect to be on these medications forever?

Dr. Lindsay: It is likely that you will need to remain on flecainide or another antiarrhythmic medication unless you undergo an ablation procedure to cure the atrial fibrillation. Further information is required to determine whether you are a good candidate for an ablation. You will need some form of anticoagulation. Depending on your risk factors, warfarin may be your best option.

boss302:I have had afib for about a year now and failed Flecanide but am doing quite well on Multaq. Havn’t had any episodes for about 4 months now. I am 57 and in good general health other than the Afib. Should I consider an ablation procedure now or wait until I fail Multaq. My Dr. says the drugs will eventually fail so why not do an ablation now while I am relatively healthy and my body can take it.

Dr. Lindsay: There is no rush to undergo an ablation as long as you are doing well with the medication. Patients in their 60s and 70s are also good candidates, so you could put the ablation off until you need to have it done.

llcoan:I have been on Tikosyn since Jan and am continuing to have daily episodes. How bad to they have to be before seriously considering ablation? What’s your usual protocol for someone not responding to Tikosyn?

Dr. Lindsay: If you are having daily episodes the Tikosyn has failed and some other treatment is required. The main options are a different medication or ablation.

llcoan:Hi I have been wearing an ecardio event monitor for 30 days (today is my last day). I am also taking Tikosyn since January. I have events daily. Some are very scary, but most are generally mild with palpitations and elevations in BP, shortness of breath and nausea. My BP has gone as high as 210/190 during these events. I have a history of triple by-pass in 96 and since then have had 6 additional stents (2 of these in the legs for PAD) Since the Tikosyn isn’t working as planned, the next step may be to consider atrial fib or the (I think it’s called Max? open heart procedure). What’s your usual protocol for someone not responding to Tikosyn?

Dr. Lindsay: The Tikosyn has failed so another approach is indicated. Further information is needed to say whether a different medication should be tried or whether you should consider an ablation.

Tickey:I’m taking ramipril 5mg (for blood pressure) and Aldactazide and Metroprolol (for mild a fib) If I have Ablation and it is successful, will I be able to discontinue any of these?

Dr. Lindsay: None of these medications prevents atrial fibrillation. Metoprolol is useful for reducing your heart rate when you have atrial fibrillation. If you underwent a successful ablation you would not require metoprolol unless it is needed for your hypertension.

Altair:I am a Prostate Cancer survivor who has bee injecting a drug formulation called tri-Mix for 7 months with great results. Can this drug cause me to experience flutter and A- Fib last week 2 times? Is there any evidence that Tri-Mix injections can cause A-Fib?

Dr. Lindsay: I do not know of any data relating this drug to atrial fibrillation.

aunr94:Are beta blockers contraindicated in patients with bradycardia and hypotension? If so, is the “pill-in-pocket” approach preferably?

Dr. Lindsay: It would be difficult to use a beta blocker in a patent with bradycardia or hypotension because the beta blocker would make these problems worse.

pcdad:Should someone with stage 2 kidney disease take multaq?

Dr. Lindsay: Multaq is metabolized by the liver and can be used in patients with renal disease.

jsr1313:After a failed trial of Multaq, HR in 40’s, SOB, edema then rash, MD suggested 2 other possible antiarrhythmics, both requiring in-patient to start. I opted to wait on a second trial. What are the risks/benefits of adding another antiarrhythmic versus just continuing my current beta blocker with Pradaxa alone? Continue to have episodes of A-fib; had 2 TIAs in March with no apparent residual problems. Thank you.

Dr. Lindsay: Beta blockers do not prevent atrial fibrillation, they only help to control the rate. If you want to suppress the atrial fibrillation you will need to change medications.

tennisprofred:After my first episode of afib a yr ago I wore a halter monitor and then a monitor for 10 days—no afib then a second episode 2 months ago – i am on multaq—none since how concern should I be about future episodes?

Dr. Lindsay: It is likely that the atrial fibrillation will recur at some point, but as long as you are doing well with the Multaq I recommend that you continue to take it.

lkerry:The price of Multaq is the only thing that is not effective. Since the doctor suspects I may have SVT vs. Afib, is this a recommended med? Also, is tikosyn superior to sotalol?

Dr. Lindsay: There is a difference between SVT and atrial fibrillation. Multaq is indicated for atrial fibrillation, but there are better options for SVT. There are no studies that directly compared Tikosyn to sotalol. My impression is that Tykosyn may work when sotalol is ineffective.

Huber:Is there any time limitation on how long one should be on multaq if it is working? What are the known side effects if any on being on the drug for long periods?

Dr. Lindsay: The main concerns about Multaq are gastrointestinal side effects and bradycardia. Rare liver failure has been reported recently by the FDA.

lkerry: My EP is not sure that my AFIB diagnosis by a Cardiologist was correct. The monitor captured a 220 bpm heart rate. He thinks I might have SVT, instead. He said he would talk with the other EPs in the practice. In the meantime, he says I could go off of Multaq and stay on (and increase) my dosage of metoprolol, that might be beneficial to the SVT. I am wondering if I should slowly come off multaq, or does it matter if all I have is SVT? Thank you

Dr. Lindsay: I think the advice given by the electrophysiologist is appropriate. The management of SVT might be very different so the correct diagnosis is important.

Surgical Treatment of Atrial Fibrillation

GT:I actually have two questions: 1) after still being drug dependent (Rythmol SR 325 twice a day) after two ablations at Strong Memorial Hospital, what are the chances that a type of “mini Maze” procedure would be a successful procedure to consider. I guess I am looking for some type of “real world/accurate” percentage of success value. There seems to be very different definitions of “success”. The real world definition of success is no A-Fib, and no drugs. 2) Also what are the chances of developing either pulmonary stenosis, or pulmonary hypertension after two ablations, and how easy is it to determine if someone has developed such (are there simple tests)? Thank you, GT

Dr. Gillinov: With a “classic Maze” your success rate likely exceeds 80%. With one of the less invasive approaches, the success rate probably falls into the 60% to 70% range, depending upon your particular characteristics. Pulmonary vein stenosis may cause shortness of breath, but is often asymptomatic. If you had further therapy for your AF (an intervention or operation), you would have a CT scan to assess your pulmonary veins.

Dr. Lindsay: With regard to pulmonary vein stenosis the surgical approach is not likely to increase that risk and whether another ablation would affect this—it would depend on the first two procedures.

chrisb:Can you please comment on the best current thinking regarding removal of the LAA? I have a thoracoscopic maze procedure scheduled for persistent afib, otherwise healthy heart, and am concerned about reports that the LAA plays important hemodynamic and endocrine functions and is perhaps best left intact.

Dr. Lindsay: There is no clear evidence that the LAA plays an important role, although we know it does play a role in clot formation and stroke in patients with AF. For that reason, I would recommend that the LAA be clipped or removed at the time of surgery.

cecchinicc:My mom is scheduled for using the Hansen Medical’s Sensei X Robotic Catheter System which they have only had for one year. Do you recommend this method? Can you recommend any doctors that perform the ablation surgery at that hospital or in Mesa, AZ. that she can see for a second opinion or to have someone with experience?

Dr. Lindsay: There is no evidence that robotic or magnetic navigation improves the success rate of the procedure or reduces complications. The most important factor is whether the center where the ablation procedure is performed has an experienced group of nurses and physicians that do a large number of ablation procedures for atrial fibrillation with good outcomes.

DeeThree:If the left anterior appendage is where most clots form, would not the minimally invasive Wolf procedure be a better choice? How many of these minimally invasive Wolf procedures have you performed at Cleveland Clinic?

Dr. Gillinov: This procedure has limited results. We do not currently favor it.

tlg43: Is the Maze procedure, during open heart surgery, more effective with better long term results than minimally invasive surgery for AF?

Dr. Gillinov: It is, with a success rate of about 90% depending upon patient characteristics.

Surgical Treatment vs. Catheter Ablation

David: In your AF treatment guide you mentioned keyhole surgical techniques. This is similar, I assume, to the Wolf Mini-Maze procedure? I have several questions concerning the Mini-Maze approach vs. Catheter ablation. 1. Do you provide both options, and what is the “cure rate” for each? 2. If it is true that most clots form in the Left Atrial Appendage, would not surgical treatment be preferred over catheter ablation? 3. Does the mini-maze procedure require use of a ventilator? I understand it requires full anesthesia (compared to ablation.) 4. If otherwise healthy, how does having prior open heart surgery and vein grafts affect the treatment options?

Dr. Gillinov: If you have prior open heart surgery and you are going to have a procedure for your AF, I would recommend a catheter ablation. Prior open heart surgery makes the keyhole type Maze procedures far more difficult.

Dr. Van Wagoner: Yes, thrombus formation in the left atrial appendage is the most common cause of stroke associated with AF, and these thrombi account for a significant fraction (20-30%) of embolic strokes in older individuals. Thus, for individuals with significant stroke risk, removal or closure of the left atrial appendage may significantly lower this risk.

Catheter Ablation for Atrial Fibrillation

TK:67 year old male, in excellent health. Easily pass for someone in his early 50s. I am 5’7″, 166 pounds, well muscled. Lifting weights since age 16, and running. Work out 3 times a week. 3 years ago started having infrequent (5-8 weeks apart) episodes of A-fib, lasted anywhere from 2-18 hours. I feel when they start, and end. Daily meds to are 1) Aldactazide 25/25, one half tab daily, 2) Metroprolol Succinate 1 1/2 tab, and 3) Ramipril 5mg one tab. Meds result in very mild episodes. No negative side effects from the meds. Now, upon onset, I take 300mg of Flecinide, which results in a normal rhythm within 30 minutes to 1 1/2 hour. I’ve read about a surgical procedure that can correct the “electrical problem” that causes A-fib. It requires going into the heart chamber through the femoral artery and “scarring” the portion of the wall that causes the electrical anomaly. The procedure sounds frightening to me (never had any surgery). If possible, I’d like to get off some of the meds I take. Can you tell me: 1) How long does the procedure typically last; 2) is it under a general? 3) is it outpatient; 4) what are the risks; and 5) what is the success rate.

Dr. Lindsay: Catheter ablation of atrial fib takes several hours to perform—the success rate depends on several factors. But in your case, it is probably in the range of 75% for a single ablation procedure based on results at the Cleveland Clinic. The risk of a serious complication is in the range of 1–3 percent. You should meet with an experienced electrophysiologist if you want to discuss this further.

az1435t:afib/flutter ablation Mar 2010; events occurring 1/month. Dr thinks now atrial tachycardia; suggests drugs. BP runs in 90s. Wearing event monitor now. Drugs vs. ablation—your thoughts?

Dr. Lindsay: Several clinical trials have shown that ablation procedures have a higher success rate than medications. None the less, there are risks with ablation procedures so we generally try one medication first. There is a national study called CABANA in progress to compare ablation procedures to drug therapy. I suggest you meet with an electrophysiologist to discuss these options further

glevanow:I was diagnosed with Lone AFIB in 2004 and went to CCF for treatment options. DCC and drug therapy was recommended. This restored me to NSR until 2010. I returned to the CCF for catheter ablation in September 2010. It was unsuccessful. I had a 5 Box Thorascopic Maze. This was also unsuccessful. I have since tried DCC and different antiarrhythmic drugs several times. Conversions lasted only from a few days to a few weeks. Due to all of the drug suppression therapy I had to have a pacemaker implanted in March 2011. I have read that repeat catheter ablations including CAEF can cure AFIB. My question is: would a repeat catheter ablation with a CAEF have a reasonable chance of curing me?

Dr. Lindsay: Given the history you have provided, the success rate for another ablation procedure would be relatively low. Ablation of CAFE has increased the success rate according to some studies but there is no absolute consensus about this issue.

stevedon41:I have paroxysmal a-fib and am scheduled for an ablation in early July. I have only had approx. 4 episodes since my first in Sept. 2008 (had cardioversion in Sept. 2008). All episodes returned to normal SR on their own. How ill I know if the ablation is successful if I don’t have an episode for months or longer after the ablation? Thank you. Please note that my ablation will be at the Cleveland Clinic.

Dr. Lindsay: It is more difficult to judge the long term outcome if the episodes are infrequent before the ablation procedure. In your case, it might take a few years before we would be absolutely certain.

gnaplus:The best advice regarding having an ablation is to get a doctor who has done hundreds of them and has a high success rate. Yet, when I asked about the doctors’ records at both the Cleveland Clinic and Vanderbilt Hospital, no one really knew who or where I could get this information. I have several related questions: 1. If a record is being kept, are these statistics generally kept by each doctor or by the hospital? 2. The counting of procedures should be rather straight forward but how are most doctors/hospitals measuring outcomes? Is there a common definition of a “successful outcome”? 3. If one is considering an ablation and wants to get a doctor and institution with the best ablation records, what’s your advice on the best place for that person to go to get that information? Thank you.

Dr. Lindsay: The Cleveland Clinic performs approx 700 ablation procedures for afib each year. Many are referred from other hospitals where ablation procedures have been unsuccessful. Or—if there were additional risks. It is difficult to compare outcomes when some hospitals do more difficult or risky procedures.

We have a group of physicians with extensive experience and we have published our results. Our outcomes books are published on our website. The accepted definition of success is that the patient does not have documented symptomatic or asymptomatic afib lasting more than 30 seconds beginning 3 months after the procedure.

ralphgS:I am a 66 year-old male who has intermittent AFib which first appeared in early 2011. A cardioversion procedure on 4/7/11 failed. I am currently taking Diovan, Coreg CR, Multaq and Pradaxa. My blood pressure has been significantly reduced (typically 105/70) and disturbing side affects have moderated. Should I continue with medication or proceed to PVAI? What is the likelihood that PVAI—if initially successful in restoring normal heart rhythm —will still be successful after 1 year and 5 years?

Dr. Lindsay: It would be fine to stay on meds if you tolerate it. If not, you can try an alternative med or discuss the ablation procedure with an electrophysiologist. We have examined our long term success rate for patients who appear to be cured at one year – our data shows that the risk of late recurrence at 5 years is about 8 – 9 percent.

JayB:Please comment on the success rate of patients in chronic AF (> 1 yr. in AF) and who are status post ASD repair of the secundum type. What type of ablation procedure is typically used for this group of patients (radiofrequency, cryoablation, hybrid approach—combined surgical & catheter ablation?).

Dr. Lindsay: The success rate would be substantially lower in someone who had been in atrial fib for more than a year and had undergone prior heart surgery. You would not be a good candidate for “mini maze” due to prior scarring from prior open heart surgery. In my opinion, your main option would be a catheter type procedure. In regard to the type of energy, cryoablation is only recommended for paroxysmal atrial fib. It is likely that you would require radiofrequency ablation if you underwent a procedure.

nutzy:I Suffered many years from persistent atrial fibrillation because my mitral valve problem. I had undergone mitral valve replacement with the prosthetic one and MAZE procedure on December 2002.The maze procedure was unsuccessful (my left atrium was moderately dilated:4,9) .MY EP thought that I need a touch up to correct the Maze but the final decision was negative because the prosthetic valve. I TRIED most of the antiarrhythmic drugs .amiodarone works great but stopped after awhile because TX.. Now I’m on MULTAQ for almost a year but alternative period atrial fibrillation with sinus rhythm. I TAKE bisoprolol fumarate a high dose also .What can I do? I read a lot about AV node ablation but I can”t decide to that last chance. WHAT IS YOUR OPPINION? There is some hope for people like me?

Dr. Lindsay: We have performed ablation procedures in patients with prosthetic valves. The success rate is lower and yet many patients appear to be cured. Additional information is required to provide more specific recommendations.

llcoan:For a pt who was unsuccessful with Tikosyn, would ablation automatically be the next option? I’ve had open heart triple bypass and have 6 stents (2 for PAD). Under what circumstances does the Mini Maze come into consideration?

Dr. Lindsay: You would not be a good candidate for a “mini Maze” because of your prior surgery. You may be a candidate for ablation.

Huber:What are the benefits of cryoballon ablation freezing as opposed to heat?

Dr. Lindsay: There are no trials that have directly compared outcomes with the cryoballoon to ablation with radiofrequency energy. Based on published reports, the risk of stroke and phrenic nerve paralysis are higher with the cryoballoon than we have reported with radiofrequency energy. The success rate with the cryoballoon is not higher. There is no proof that risk of esophageal injury is reduced. In my opinion, there is no proven benefit.

DeeThree:Can you tell me a little more about the “investigative procedure” of closing of the left anterior appendage during ablation. This seems like a no brainer with so much documentation indicating this appendage’s correlation with stroke.

Dr. Lindsay: The left atrial appendage closure device is investigational. According to protocol it is not done at the same time as the ablation procedure. The study is designed to show whether the closure device is as effective as warfarin. Patients must be randomized to either the closure device or warfarin.

rwill1011:What is the name of the type of ablation procedure used at the Cleveland Clinic, and has your success rate or the procedure used, which might have been largely influenced by Dr Natale changed since he has left?

Dr. Lindsay: We usually refer to the procedure as a pulmonary vein antral isolation because it includes tissue surrounding the veins. With all due respect to Dr. Natale who has made important contributions to the field, the success rate has not been affected by his departure.

rwill101:“patient does not have documented symptomatic or asymptomatic afib lasting more than 30 seconds beginning 3 months after the procedure.”—Is this without rhythm control drugs?

Dr. Lindsay: Our success is reported as the absence of atrial fibrillation without drugs.

Tickey:Is ablation done under a “local”, and is it an outpatient or overnight procedure?

Dr. Lindsay: All patients are observed overnight. The decision to use local anesthetic with sedation as opposed to anesthesia depends on patient preference, weight, and the presence or absence of sleep apnea.

Valve Disease and Valve Surgery and Atrial Fibrillation Treatment

Ed: I have a St Jude mitral valve. Cardioverted May 3rd but and my rhythm is currently slightly out of sync. Was on Amiodarone for 8 yrs but recently switched to Multag. Since it had less side affects. I heard that there’s a drug called Tikosyn. My question what’s the better drug (least side affects) to maintain a normal rhythm. My doctor said the mechanical valve would make an ablation more risky. What risks are there? Thank you

Dr. Lindsay: Both multaq and tikosyn have been approved for treatment of atrial fibrillation. If the multaq is working I would recommend staying on the drug. If it is not effective or well tolerated then tikosyn would be a good option. Ablations are performed in patients with mechanical valves. The risks are not substantially greater though the success rate is somewhat lower due to scarring related to surgery.

elcheapo: 77 year old male. Dr.G replaced aortic & mitral valves (tissue) repaired tricuspid and closed hole between two chambers. Maze not done due to time constraints. Feel great take no rhythm meds. do take coumadin. Would not know I have A-Fib if not told. Should I be trying to have it corrected?? Is life cycle shortened significantly if left as is?

Dr. Lindsay: Two clinical studies have shown that in patients who tolerate AF well, there life cycle is not shortened, nor do they have a higher incidence of heart failure or stroke. This assumes that some form of anticoagulation is in place.

fpilla:Thank you for this presentation and opportunity to ask questions. I have two. related to my aortic valve stenosis induced AFib. Which medications do you find are best to prevent or diminish the incidents of AFib. Next, what is the mortality risk associated with AFIB. I’m 78 and developed the AFib about one year ago. My valve area as shown on Echocardiogram is 0.9. No other subjective symptoms. I hope I might safely avoid replacement until the minimally invasive techniques are common place for non- high risk patients.

Dr. Lindsay: No single medication is best for all patients. It is unlikely that the atrial fibrillation will determine how long you live. The aortic stenosis is far more important.

Tru: Does it make a difference if you have a bioprothestic valve as far as risks and outcomes are concerned vesus a mechanical valve? for an ablation

Dr. Lindsay: One of the concerns about the mechanical valves is that an ablation catheter could become trapped in the mechanical leaflets. We have performed a large number of ablations with mechanical valves without this complication. The success rate is not as high for patients with mechanical valves, but it is still reasonably good. Our results have been accepted for publication later this year.

Einstein:How is af or pvc related to av regurgitation? would af push you towards repair or replacement of aortic valve? dr gillinov, do you do av repair frequently, eg how many in the past year? thank u.

Dr. Lindsay: AV regurgitation leads to dilation of the heart and stretching of muscle fibers. This is a factor in why patients with this problem may be prone to atrial fibrillation or PVCs.

pdmock:Good Morning from Las Vegas, Doctors. I had a Mitral Valve repair done in 2005. In 2009, I developed A Fib. I had a Medtronics Defibrillator installed in Aug 09 and have been on various meds since then. The latest Echo reports the annuloplasty ring installed, but shows slight thickening of the leaflets, and there is a mild regurgitation again. My questions are: (1) Did the surgical repair of the mitral valve induce the fibrillation; (2) will it degenerate from a murmur to a gusher again; and can the valve be repaired again?

Dr. Lindsay: While these changes may contribute to why you have atrial fibrillation, other factors may be involved. Based on your description, it sounds unlikely that you are at risk of another valve operation in the near future. You should discuss this with your cardiologist who has more information.

Pacemaker Therapy for Atrial Fibrillation

Horstmann: As a long time runner, I have always had a low heart rate. After my AFib diagnosis about 5 years ago, I was put on Atenolol which further lowered the heart rate, to the point of needing a pacemaker for bradycardia. Interrogation of the PM after 6 months (January ’11) showed 5 or 6 minor episodes of Fib, lasting seconds or a couple minutes. Two questions: Do you find that having a PM, often keeps AFib at bay? Secondly, I am taking both atenolol AND propafenone. Since I am being paced at 80 bpm constantly, why would I need not one, but two beta-blockers? Are they really doing anything to control the AFib? Thanks, Doctors, for doing this chat…we all learn so much!

Dr. Lindsay: Pacemakers are not effective at preventing atrial fibrillation. Propafenone is a relatively weak beta blocker but it has other properties that help prevent afib. It is likely that atenolol was prescribed in case the propafenone does not prevent afib.

Horstmann:Just thought of another concern…does having this pacemaker now preclude an ablation should I have problems with AFib in the future? Thanks!

Dr. Lindsay: Pacemakers do not preclude an ablation procedure.

CSD77:I developed AFib three years ago after pancreatitis and then gall bladder surgery. In Feb. of 2009 I had a SCD and MI in the LAD. Two stents were implanted the same week and then an ICD. I am on Sotolol 40mg, 3x’s daily; Carvidilol (small dose); Pravastatin; Plavix; 2 81-mg aspirin per day. My Afib seems to be increasing. Had a cardioversion Dec. 28 and in May. When I’m in Afib, it is completely debilitating—short of breath, light-headed, unable to function. I am 77 years old. Am I a good candidate for ablation? Thank you in advance. Carolyn Sorry, the heart attack was in 2010. Carolyn

Dr. Lindsay: You may be a candidate for ablation of atrial fibrillation. The success rate would not be as high in your case as in other patients because of underlying heart disease. Perhaps another medication would be a good option.

lrg1742:How do you define a successful catheter ablation? What are your success rates for a single or multiple ablations?

Dr. Lindsay: We define success as the absence of documented atrial fibrillation after an ablation. Several factors determine the success rate. We have published our results. The success rate for a single procedure is in the range of 75% for paroxysmal atrial fibrillation. The cumulative success is as high as 90% in patients who have undergone more than one ablation. In contrast, the success rate is lower for patients with long standing persistent atrial fibrillation in whom the overall success rate is in the range of 50-65% for a single ablation procedure and higher for those who undergo more than one procedure. The presence or absence of underlying heart disease, obesity, and sleep apnea are among the other factors that have an impact on success.

newholland55_1: I am a 55 year old male who has had infrequent episodes of a-fib for the past six years. They always occur at night after I go to sleep and are always accompanied by stomach distress (lots of belching). Have read recently about esophogheal problems as a trigger for a-fib—any validity to this? My episodes last from five minutes to eight hours and go anywhere from six months to eighteen months between episodes. I exercise frequently and am in overall good health. Are there any advantages to considering ablation now or should I wait to see if episodes become more frequent? Current meds are 50 mg Metoprolol, 10 mg Crestor, and full strength aspirin.

Dr. Lindsay: It is possible that esophageal problems provoke a reflex that makes you more prone to atrial fibrillation. Sleep apnea is another potential factor.

Motocat:How does an enlarged left atrium and mitral valve regurgitation caused by af fib affect the success of ablation?

Dr. Lindsay: The success rate would be lower. The degree of impact depends on the severity of these conditions.

aplayeru: When is ablation appropriate?

Dr. Lindsay: The clearest indication is to alleviate significant symptoms in patients for whom medications are not effective or well tolerated.

boss302:Which method achieves the best results long term: radio energy ablation or cyro ablation?

Dr. Lindsay: There have been no direct comparisons of these technologies. Beware of industry sponsored claims.

Heath:What is an ablation?

Dr. Lindsay: This term refers to destruction of selected tissue that causes heart rhythm abnormalities. The most common method is the use of radiofrequency energy to burn the tissue. Cryothermia has been approved for selected patients.

bjwhit:What are some alternatives to ablations?

Dr. Lindsay: The main alternatives are medications or the Maze operation.

stevedon41:I am 60 years old, have paroxysmal a-fib and want to reduce medications, be proactive in avoiding future episodes and be able to increase my exercise routine. I am currently afraid to push myself. Will an ablation help ??

Dr. Lindsay: Either medications or an ablation might help you to achieve an active life.

druppel: 63 yo F with chronic AF. Enlarged atria. Told I do not qualify for ablations. Had PE with second recurrence of AF. What qualifies one to be a candidate for ablations?

Dr. Lindsay: The decision to perform an ablation hinges on the severity of symptoms, the probability of success and the risks. We try to balance these factors for each patient when we make the recommendation.

P544: WHAT does an evaluation for an ablation procedure entail?

Dr. Lindsay: Key components are a careful history and physical to assess the severity of symptoms and the likelihood that the ablation would improve the patient’s quality of life. Certain laboratory studies such as echocardiograms help us to assess whether heart disease is present and could affect outcomes.

cwelniak:Does the Clinic have experience with hybrid ablations? If so, which patients are best suited for this approach?

Dr. Lindsay: We work closely with our surgeons who are both friends and colleagues, but we decided not to perform “hybrid” ablations. We generally decide which would be most appropriate for our patients, catheter ablation vs surgery.

DennisH:How does Typical Atrial Flutter Ablation result in Atrial Fibrillation, as recently happened to me?

Dr. Lindsay: Atrial flutter is a electrical circuit that spins in a circle. Sometimes the atria cannot tolerate the rapid rate and degenerate into atrial fibrillation, which is a more disorganized rhythm.

Cardioversion

missey1943:The doctors found that my husband had an irregular heart beat (AF) and they have put him on coumadin. Why did they not try to shock the heart back into regular rhythm? In 76 years this is his first time with an irregular beat. He had test last year and the doctor said his heart was working A OK

Dr. Lindsay: You would need to ask them this question. I suspect they thought he did not have any severe symptoms and decided to leave him in atrial fibrillation. I would need additional information to decide whether or not I would have made the same decision.

mylake:I am 74, had A fib since last November, and am scheduled for cardioversion last week of June. Is it safe?

Dr. Lindsay: The risk of stroke or other complications is very low provided that you have been appropriately treated with warfarin or dabigatran prior to the cardioversion.

widgeon:Besides cardioversion, what are the accepted treatments for afib?

Dr. Lindsay: Cardioversion interrupts the atrial fibrillation, but it does not prevent a recurrence. Medications or ablations are used for that purpose.

Blood Clot Risk and Anticoagulation

Carl:I am 73 year old male who has had afib since 1964 I was taking coumadin for about 12 years with no problems in dec of 08 I was diagnosed with prostate cancer and had 42 radiation treatments in nov 09 I started bleeding at the rectum which required blood transfusions I had to get off coumadin so I had an ablation done at(a hospital. it did not work so they did a second ablation which did not work so they ablated my av node and put in a two chamber pacemaker I still have afib and am afraid of clots forming, would I be able to get the mini maze operation with the pacemaker in

Dr. Lindsay: I am not optimistic that the mini maze would increase the likelihood of maintaining sinus rhythm However, depending on how the procedure was performed the surgeon may clip the right atrial appendage and eliminate the risk of clot formation. Another option is an investigational procedure that is performed with a catheter technique in which a device plugs the opening of the left atrial appendage to eliminate the need for coumadin. You can contact our office if you would like to discuss this further.

symmons: My EP wants to do an ablation, but I take indomethacin due to chronic gout and costocondritis, so I’m not able to take coumadin for 4 months. Is pradaxa a possibility? He says its not. Are there any other options, like a TEE just before the ablation. I’ve also had bad side effects from flecainide and multaq did not help. Any suggestions?

Dr. Lindsay: Further information is needed to assess your risk of stroke. The risk of taking indomethacin with pradaxa is probably the same as with coumadin. While treatment with indomethacin does not absolutely eliminate the possibility of doing the procedure I would need to know more about your bleeding risks to provide an assessment of the procedure.

Heath:Pradaxa has been approved for dealing with clots generated by atrial fibrillation. How are atrial fibrillation clots different than those generated by an artificial heart (aortic) valve?

Dr. Lindsay: Atrial fibrillation causes clots to form on the left atrial appendage because of stagnant blood flow in that area. It is not clear how that differs from clots that form around aortic valves, nor is pradax approved for anticoagulation in patients with artificial heart valves.

Chowser:In the 2009 webchat on a fib, a questioner mentioned that longterm use of coumadin could result in greater probability of bone fracture—something I’d never heard. Is this indeed the case? I have last year’s bmd indicating severe osteoporosis (no “hump” yet) at 78. Have been taking coumadin since 02 when a fib first diagnosed. Does this indeed put me a greater risk for fracture? Many thanks!

Dr. Van Wagoner: Yes, warfarin can increase the risk of osteoporosis. Some of the newer anticoagulants (dabigatran, rivaroxaban) act by a different mechanism, and should not have this side effect.

Yes, warfarin can increase the risk of osteoporosis. Some of the newer anticoagulants (dabigatran, rivaroxaban) act by a different mechanism, and should not have this side effect.

M. Fusaro, G. Crepaldi, S. Maggi, A. D’Angelo, L. Calo, D. Miozzo, A. Fornasieri, and M. Gallieni. Bleeding, Vertebral Fractures and Vascular Calcifications in Patients Treated with Warfarin: Hope for Lower Risks with Alternative Therapies. Curr.Vasc.Pharmacol., 2011.PM:21623708

Dr. Lindsay: Don’t lose the forest through the trees—the risk of osteoporosis associated with coumadin is relatively low but strokes can be devastating—so I would not stop taking coumadin due to your concerns about osteoporosis.

tlg43:I had single bypass surgery and a maze procedure to fix by continuous Faith DR. Gillinov two years ago. Since then I have had absolutely no problems or side effects. A few weeks ago I visited a cardiologist @CC and one of the questions I asked him was if it was OK to get off of Coumadin. Basically he said if I wasn’t having any problems taking it, I should not quit. It is still a hedge against having a stroke. My local cardiologist says basically the same thing. What is your advice and opinion?

Dr. Lindsay: Additional information is needed to answer this question.

widgeon:What percentage of people with afib have strokes?

Dr. Lindsay: The risk of stroke is in the range of 1% for those who are treated with anticoagulants and as high as 8-10% for those who are not. There is evidence that approximately 15% of strokes are caused by atrial fibrillation.

graham:Do your recommend at this point in time switching from warfarin/coumadin to the new afib medication that is being marketed as a ” better ” but more expensive drug

Dr. Lindsay: Dabigatran is a new medication. Clinical trials have shown that the effectiveness and risks are similar to warfarin. I generally reserve dabigatran for patients in whom it is difficult to adjust the dose of warfarin to keep the INR in a therapeutic range.

stevedon41:You answered my question regarding my paroxysmal that has occurred only a few times since 2008. If one must wait possibly a few years to determine ablation success, would one have to stay on warfarin, atenolol during those years ? Thanks again.

Dr. Lindsay: It depends on your risk of stoke. If you have several risk factors I would recommend warfarin. If your risk is low, aspirin might be an alternative. It would be reasonable to stop the atenolol and resume it only if the atrial fibrillation recurred.

mphenn6656:I am reading the atrium appendage is the most common place for thrombus. I had mine during a mini maze…why would I still need to be on Warfarin?

Dr. Lindsay: I generally stop warfarin in patients who have had a successful Maze operation with removal of the left atrial appendage.

jpvaugh:I have chronic AFib and had AV replacement 11/1/2010 with a bovine valve. The Maze procedure for the AFib did not work. I just switched from Coumadin to Pradaxa and so far I’m ok. Do you know of any effects Pradaxa has on tissue valves?

Dr. Lindsay: No. I am not aware of any effects on tissue valves.

frpock_1: I have been taking Warfarin for over a year with no side effects, my Dr recommends a new medication which does not require the INR monitoring. What’s you experience been with this new med?

As above.

Motocat:Can ablation be safely done if taking pradaxa instead of coumadin?

Dr. Lindsay: Our policy is to stop the dabigatran the day prior to the ablation and resume it immediately after the ablation.

millafib:I just got a prescription for dabigatran (Pradaxa) to replace my Coumadin. Since I have to take it twice a day, is it OK to take it with my twice a day Rythmol SR?

Dr. Lindsay: I am not aware of any interaction but suggest that you check with your pharmacist.

Causes or Triggers of Atrial Fibrillation

Valerie:Patient has had a-fib for many years. It was under control with medication prior to a car wreck in April, 2009. Immediately after the wreck, the a-fib returned. In May 2009, patient required cardioversion that did not correct the a-fib, but heart returned to normal rhythm several weeks later. Is there literature linking trauma such as a car accident to the recurrence of a-fib which was previously controlled with medication? If so, do you know the name(s) of the study(ies)? Thank you for your time.

Dr. Van Wagoner: There are not systematic studies linking blunt trauma as experienced during an auto accident with AF. However, AF is very common following cardiac bypass graft or valve repair surgery. Cardiac surgery causes direct cardiac trauma, leading to inflammation of the heart (1). Studies from the Cleveland Clinic were among the first to make the broader connection between inflammation and AF (2). As was the case for the patient you describe, AF following cardiac surgery often resolves in the weeks following surgery, coincident with healing and a reduction in inflammation.

P. Bruins, Velthuis H., A. P. Yazdanbakhsh, P. G. Jansen, F. W. van Hardevelt, E. M. de Beaumont, C. R. Wildevuur, L. Eijsman, A. Trouwborst, and C. E. Hack. Activation of the complement system during and after cardiopulmonary bypass surgery: post surgery activation involves C-reactive protein and is associated with postoperative arrhythmia. Circ. 96 (10):3542-3548, 1997.PM:0009396453
M. K. Chung, D. O. Martin, O. Wazni, A. Kanderian, D. Sprecher, C. A. Carnes, J. A. Bauer, P. J. Tchou, M. Niebauer, A. Natale, and D. R. Van Wagoner. C-reactive protein elevation in patients with atrial arrhythmias: inflammatory mechanisms and persistence of atrial fibrillation. Circ. 104:2886-2891, 2001.PM:11739301

Dr. Lindsay: There are no studies correlating blunt trauma due to an auto accident with atrial fibrillation.

katerina:I have been taking plavix and propafenone since my ER visit on May 5, 2011. I am 52 and was very active prior to this problem. I have two careers and am a mother of teenager boys. I seem to get this problem when I am stressed or overtired. I can’t sleep and now have to take a sleeping pill which only me sleep for 4 hours or so. Can diet help me? I don’t drink coffee, eat chocolate, or sodas. I am 5’6″ and weigh 126lbs. I eat well so I don’t know why I have this problem? Please advise. Can omega-3 pills/liquid help with AF?

Dr. Van Wagoner: Stress is a risk factor for AF, perhaps due to increased sympathetic nerve activity. It sounds like stress reduction would be helpful, if challenging. If you are able to make time for exercise, this may help with sleeping and stress reduction. In a recent randomized clinical trial, short-term use of omega-3 pills did not help to prevent AF recurrence. As half of the recurrences occurred in the first two weeks of treatment, it is unclear if a benefit would have been detected with longer treatment. Omega-3 fatty acids can help to slow heart rate. If your resting heart rate is elevated, there may be a possible benefit.

P. R. Kowey, J. A. Reiffel, K. A. Ellenbogen, G. V. Naccarelli, and C. M. Pratt. Efficacy and safety of prescription omega-3 fatty acids for the prevention of recurrent symptomatic atrial fibrillation: a randomized controlled trial. JAMA 304 (21):2363-2372, 2010.PM:21078810

minmom68:Both my mom and dad are diagnosed with Arial Fibrillation. My dad was diagnosed 2 years ago at 78 and my mom has just been diagnosed at almost 80 yrs. Is Atrial Fibrillation hereditary and is there anything my brothers and sisters can do early on to prevent this for us. Also, both my parents are on Warfarin but I have a close friend (in her 70’s) that has Atrial Fibrillation who is not on any blood thinner. What are some reasons a Dr. might feel thinners aren’t necessary? Thank you.

Dr. Van Wagoner: You note that both parents have a history of AF, although this developed at an older age. AF risk can be inherited, and the risk is increased if both parents have a history of AF. The hereditary risk association is strongest when AF occurs at an early age (<65). For an individual with one parent with early onset AF, risk is ~1.5x increased; with two parents the risk is ~4-5x increased. In your case, the risk is lower, as AF is increasingly common with approximately 10% of individuals over the age of 80 affected by AF.

With respect to preventing AF, you can: 1) maintain a healthy weight, 2) exercise regularly (walking is fine), 3) monitor and control your blood pressure. Use of warfarin (vs. aspirin) is based on the number of risk factors for stroke. This is related to age, history of stroke, hypertension and heart failure. If the patient is young (<65) and there are no other risk factors, stroke risk is relatively low and aspirin might be an appropriate alternative.

Blinfas:I am 63 years old and have had skipped beats for 3-4 months and recently diagnosed with AF. I am in very good physical health and work out 3-4 times a week. i do have sleep apnea due to a small lower jaw and wear a CPAP mask, effectively. I recently had a regular stress test, an echo cardiogram and a nuclear stress test and all were normal. My doctor is young and thus inexperienced. I like the idea of arterial ablation to possibly cure all. What steps should I take from here to see what is best to cure me of AF, if possible.

Dr. Van Wagoner: Sleep apnea causes a decrease in blood oxygen levels during sleep (hypoxia). This causes an increase in sympathetic nerve activity, and changes in heart function and structure that can increase risk of hypertension and AF. CPAP can be an effective treatment for sleep apnea, and over the long term, may have a significant protective effect on blood pressure and AF (ref below). If the primary cause of the sleep apnea is structural, it is possible that oral surgery may be helpful. Although atrial ablation may provide temporary relief, the hypoxia resulting from sleep apnea is a significant factor for continued remodeling of the heart that may promote future episodes of AF.

R. Kanagala, N. S. Murali, P. A. Friedman, N. M. Ammash, B. J. Gersh, K. V. Ballman, A. S. Shamsuzzaman, and V. K. Somers. Obstructive sleep apnea and the recurrence of atrial fibrillation. Circ. 107 (20):2589-2594, 2003.PM:12743002

Dr. Lindsay: If your sleep apnea is being treated effectively you may be a candidate for atrial fibrillation ablation. In that case you should make an appointment with an experienced electrophysiologist to discuss this further.

RobertD: Other than medication is there anything I can do to prevent my heart from starting to fibrulate? Does a relaxed mode or life style help from keeping my heart from starting to fibrulate?

Dr. Lindsay: See answer to minmom68 above.

johnnnita:In January 2007, Dr. Gillinov performed a mitral valve repair procedure on me. Needless to say, I have been quite pleased with my recovery and subsequent health. I’ve also been paying attention to the issues of atrial fibrillation. During post-op while still in Cleveland Clinic hospital, I had afib. I’ve had no occurrences since, but wonder what the probability is for an event(s) for those like me who otherwise are in good health and no reoccurrence so far.

Dr. Lindsay: If you have done so well for this long, your risk of AF is not high.

Chowser:Is it true K and NaCl blood levels can influence heart electrical function? If yes, should labs be done periodically?

Dr. Van Wagoner: Yes, blood levels of Na and K affect cardiac electrical activity. If you have normal kidney function and are not on a diuretic to control blood pressure, these levels are not likely to change very much. However, labs are indicated as a part of a normal physical, or if you have renal dysfunction or are taking a diuretic that modifies salt balance.

pcdad:I’ve had AFIB for 11 years, current age 68. All of my AFIB occurrences take place early in the morning around 2 AM or 3 AM. I wake up in AFIB. What may be the explanation for this?

Dr. Lindsay: Nocturnal afib is often associated with sleep apnea so I suggest you get evaluated for that.

pcdad:Will the extended use of digoxin cause one to eventually have permanent AFIB?

Dr. Lindsay: Treatment with digoxin will not cause permanent afib.

katerina:Can hot flashes from menopause contribute to AF. When ever I get a hot flash, it provokes another irregular and racing heart beats. It usually lasts for 1 hour. Is this a problem and should I tell my doctor about this?

Dr. Lindsay: Many women note that they are prone to various heart rhythm problems when they have “hot flashes”. You should discuss this with your physician.

Lifestyle – Diet, Activity, Alternative Therapies and Atrial Fibrillation

Diet:

Mel: I am taking the following med for A-Fib: Amiodarone 400mg,Metoprolol 50mg,Simvastatin 40mg,Warfarin 5mg,Ramipril5mg and Mag,Oxide 800mg. Will drinking a glass of red wine 4to6oz. effect the medication side effect on Me?

Dr. Lindsay: It is unlikely that that will have an appreciable effect.

Chowser:My a fib is usually at or after ingesting food (esp spicy or salty) or cold drink (eg juice), tho yesterday around 7a.m. started as i was getting out of bed pre-food/drink. Is there some sensitive throat area sending nerve impulse to sinus node?

Dr. Lindsay: There are reflexes that may be provoked by swallowing, especially hot or cold drinks which can provoke atrial fibrillation in some patients.

Exercise:

Dyno:I had read that the occurrence of AF is higher in runners than the general population. Are the reasons for this understood and is there any indication that a period of deconditioning may benefit runners with AF? Could you comment on the longer term prognosis for a younger patient who has had AF cured by ablation?

Dr. Van Wagoner: You are correct that runners have a modestly increased risk of AF. Runners often have a slower heart rate than those that do not exercise, and the heart can be enlarged as a normal response to exercise. A slower resting heart rate somewhat increases the risk of initiating AF due to spontaneous activity originating in locations other than the sinoatrial node (the normal cardiac pacemaker). Strenuous exercise and running (marathons, etc.) can cause transient cardiac injury and inflammation that can promote remodeling of the atria to increase risk of AF.

Dr. Lindsay: Deconditioning does reverse many of the changes that occur with intense endurance exercise but it is not clear that deconditioning decreases AF. My impression is that the atrial fibrillation generally does not resolve.

larrymp:Barring unusual situations and conditions , after pulmonary vein ablation how many weeks should I wait before I aerobic exercise.

Dr. Lindsay: I generally recommend that patients wait 3-4 weeks. You should begin slowly and gradually increase exercise.

Motocat:Can you safely exercise with atrial fibrillation and resulting heart damage, how can you determine if the exercise you are doing is safe?

Dr. Lindsay: Patients can exercise with atrial fibrillation provided that their heart rate is controlled.

Billy:had persistent afib for 18 years with a present ejection fraction of 62%..Am 68 exercise 3-4 times a week and take 325mg of aspirin a day. pt is fine .should i take pradaxa??

Dr. Lindsay: I would recommend warfarin or dabigatran if you have a history of diabetes, prior stroke, hypertension, valvular disease, or coronary artery disease. You should discuss this with your physician who knows more about your condition.

Alternative Therapies:

Chowser:Also, do any drug-alternative techniques help stop a fib: breathing exercises, cold water on face are two I’ve seen suggested. Btw, almost always “my” a fib starts either as or after I’ve eaten–esp cold drinks and spicy or salty food, or else after I’ve been running around doing errands and am tired. Re the ingestion aspect, is some neural impulse being sent from some area of the mouth or throat to the sinus node? Again, many thanks!

Dr. Van Wagoner: You have noticed that cold water and eating can sometimes trigger AF. The vagus nerves (parasympathetic) that control digestion also have a significant impact on the atria, slowing the heart rate and causing irregular electrical activation that can initiate AF. It is interesting that strong vagal stimulation can trigger AF, while milder stimulation can sometimes terminate or prevent AF.

jimnov: What is your opinion of biofeedback to treat atrial fibrillation? I have heartmath and I have resperate.

Dr. Van Wagoner: Biofeedback is an interesting approach to AF prevention, with limited systematic study. Biofeedback and yoga affect the balance of nerve activity that affect the heart. Sympathetic nerve activity (“fight or flight”) and parasympathetic activity (relaxation) are in a dynamic balance. With aging and loss of conditioning, parasympathetic activity tends to decrease, leading to increased heart rate and a reduction in heart rate variability. Biofeedback (and yoga) may improve parasympathetic (vagal) nerve activity by teaching controlled breathing. Experimentally, vagal nerve stimulation affects heart rate variability, decreases inflammation, and helps to prevent heart failure and AF.

Q136Billy:Why dosen’t the use of co-q-10,d-ribose and carnitine Fumeratew get recognized and used in conventional treatment protocols?? Also,why aren’t Statin uses told to coq-10 all the time?? These all produce energy in the mitochondria and are very important

Dr. Van Wagoner: As you note, mitochondria are the primary site for generation of ATP in all cells, and there is active research into the impact of AF on mitochondrial activity. At present, there have not yet been systematic studies to investigate the impact of the supplements that you mention on atrial function or AF occurrence. In the case of statin treatment, although there is some evidence that coenzyme-Q10 deficiency may account for statin-induced muscle injury (1), there is not yet evidence that co-Q10 supplements can improve muscle function.

R. Deichmann, C. Lavie, and S. Andrews. Coenzyme q10 and statin-induced mitochondrial dysfunction. Ochsner.J 10 (1):16-21, 2010.PM:21603349. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096178/pdf/i1524-5012-10-1-16.pdf

Outcome and Prognosis of Atrial Fibrillation

Dyno:Regarding lone atrial fibrillation – Is the condition typically progressive in terms of increasing frequency and duration of episodes?

Dr. Van Wagoner: Lone atrial fibrillation refers to AF that occurs in the absence of structural heart disease—that is, the function of the heart is normal except for the AF. Lone AF may be caused by genetic factors, hypertension, obesity, infection, and other factors. In general, the frequency and duration of AF episodes tend to increase with age. However, the rate of progression is quite variable from individual to individual, reflecting the variable causes of the arrhythmia.

theragtopman:Hello—I’m a 43yo male and have had 2 bouts of afib over the past 3 years and they both resolved on their own. What’s the prognosis for someone like me? Were those random occurrences? Will this continue to get worse? Or ???

Dr. Van Wagoner: You do not provide enough background to give you and informed response. Relevant factors that affect your risk for more episodes of AF include family history, weight, fitness, blood pressure, resting heart rate, smoking, etc. A history of transient episodes is associated with the potential for additional episodes of AF. However, if you address the modifiable risk factors above, you can reduce or delay the risk of recurrence.

Q89Dyno:If LAF is medically controlled so that AF rarely occurs, do we expect that the condition would still progress in terms of frequency/duration of episodes so that medical control will become more challenging in time?

Dr. Van Wagoner: If LAF is well controlled and other risk factors (hypertension, weight, diabetes, etc.) are also controlled, there is no reason to expect rapid disease progression. However, the natural history of AF is such that there is a general trend for increase in frequency and episode duration with time. As noted above, individual rates of progression are quite variable.

Q91Motocat:If persistent atrial fibrillation cannot be cured, how best to mitiagate its ill effects?

Dr. Van Wagoner: The primary risks associated with AF are stroke and heart failure related. Stroke risk can be minimized with appropriate anticoagulation, and the risk of heart failure can be minimized by controlling ventricular rate during AF. You should discuss these issues with your physician.

Atrial Fibrillation and Other Associated Conditions

fairgo:What causes extensive scarring of the left atrium, my recent ablation plus amiodarone failed after 12 days of NSR can a second one be successful or does the scarring prohibit a good out come if so what other options do i have

Dr. Van Wagoner: You do not mention how far out from your ablation you are. It is not uncommon for there to be early recurrence of AF due to inflammation resulting from the procedure. This often resolves within 1-3 months following the procedure. If not, a second procedure may be useful.

Dr. Lindsay: There are occasional patients with atrial scarring related to some other problem with the heart that preceded their ablation procedure. The cause is not always clear. Patients with extensive scarring have lower success rates when they undergo ablations.

mphenn6656:I am a 55 y/o man who had a inferior MI 5 years ago. I have 6 stents in my RCA. Since then I have had A-fib and A-flutter. I had seen several Electrophysiologists and no medicine worked. I had a mini maze in July 2007 and was in rhythm till Feb 2010. F-fib once again was back, cardioversion lasted at first for 2 months then each time thereafter it progressively was shorter in duration until my cardiologist would not cardiovert me anymore. I then had a catheter ablation of bother the lest and right atriums. I had to fly to Los Angeles from Hawaii to have that since there was not a physician in Hawaii that would do it with my cardiac history. That procedure only held for 6 months before going back in a-fib again. My cardiologist has cardioverted me 6 weeks ago and his words”keeping his fingers crossed”. He states I need the pacemaker now that no other option in available to me out there. My question is….is there any new procedures which might help?

Dr. Lindsay: While it is possible that another ablation procedure might work if indicated, the success rate would be lower due to your clinical history.

Your main options are: an open chest maze operation or treatment with medications to control your heart rate. In some cases a pacemaker is necessary so that the medications could be adjusted to control your heart rate. If you would like a second opinion, please contact us.

bergie723:I at times get a rash of PVC’s that are followed by a brief 10 minute session of A-fib. Is there any connection between PVC’s and A-fib?

Dr. Lindsay: There is no clear connection between PVCs and atrial fibrillation but it is possible that the same neurologic inputs that affect one also affect the other.

bml:About a year ago, my husband had a pacemaker inserted due to a slow heart beat. Subsequently, he developed a-fib, and is on Multaq. Is there any correlation between the slow heartbeat and a-fib? He is 85 years old

Dr. Lindsay: His rate may have become slow during atrial fibrillation if the normal conduction system between the atrial and ventricles had age related changes that slowed conduction. Sometimes medications also cause this problem.

jhw10101:I had a failed attempt at TTM/5Box, and Catheter Ablation in Nov 2010 — 5Box on the right side, and a CA was attempted on the left since my atrium was enlarged. My situation is complicated with CHF. I am still in chronic afib. I have never recovered from the operation. I am more tired, more short of breath since the operation in November. I have two questions: 1. What are the special considerations I should be considering for the combination of afib and CHF? 2. How do lesions effect the heart muscle, especially regarding repeat ablations, and/or extensive lesions in the procedures. What are the negative effects extensive lesions from the 5Box, and/or repeat ablations. How much can the heart tolerate? Thank you.

Dr. Lindsay: You have a very complex history. I cannot give you meaningful advise without more extensive review of your records.

deannaf:How can you make the EP explain everything to you without them getting impatient–my EP says I am very anxious, but I found out that I have afib and c diff–it is very hard to deal with.

Dr. Lindsay: Perhaps you should try a different physician if you are unable to speak to the one you have.

folsomsteve_1:In addition to Afib, with no symptoms noticed on my part, I have Factor V Leidens. . .anything that I should be concerned about with that combination?

Dr. Lindsay: The main issue is that you require anticoagulation.

More information:

Background information about the chat
Chat transcript on the Cleveland Clinic site along with links to info on afib, upcoming chats, previous chat transcripts, and how to contact Cleveland Clinic
Profile of Bruce Lindsay, MD
Profile of David Van Wagoner, PhD
Profile of Marc Gillinov, MD

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