Transcript of Afib Chat with Cleveland Clinic Atrial Fibrillation Experts on March 6, 2017

April 4, 2017

  • Summary:  Here is the transcript of our March 6 chat with atrial fibrillation experts Dr. David Van Wagoner, Dr. Oussama Wazni, and Dr. Walid Saliba of the Cleveland Clinic answering your most pressing afib questions.
  • Transcript is reprinted with the permission of the Cleveland Clinic.
  • Reading time: Approximately 30–60 minutes

Chat Description

Atrial fibrillation or Afib is the most common heart rhythm abnormality. Over 2 million Americans are affected by AFib and while it is often a mere annoyance, it is responsible for 15% of all strokes. It can also be responsible for life-threatening medical emergencies that result in cardiac arrest and even sudden death. Cleveland Clinic afib experts, David Van Wagoner, PhD, Oussama Wazni, MD, and Walid Saliba, MD, answer your questions about atrial fibrillation and other irregular heartbeats. This chat is hosted by Cleveland Clinic and StopAfib.org.

Chat Transcript

Please note that the comments below are the opinions of the Cleveland Clinic doctors. If you quote these opinions elsewhere, please reference the specific doctor whose opinion you are quoting.

Symptoms

Geno: I am a 76-year-old male, with a pacemaker, five stents, three ablation procedures, controlled diabetes, controlled high blood pressure, and am currently in Afib about 80% of the time according to the results of my three month pacemaker checkups. With the above information, would it be realistic to consider a fourth ablation to reduce or eliminate my Afib? When I am in Afib, I am feeling okay, but lack energy and when I do something that takes exercise/energy I have to go slow and take a break due to a mild shortness of breath. I hope to be a part of the “Chat” and look forward to your answer to my question. Another ablation or not. Last but not least, is there new anything on the horizon or currently in place that would help me? Procedures or Medications?

David Van Wagoner, PhD: You note that you have medically controlled diabetes and hypertension, lack energy and tire easily. In addition to considering the role of procedures and medications, it may be helpful to consider what you can do to increase your level of fitness. Fitness can help to reduce the burden of AF, and does not take extreme measures. Helpful efforts can include taking a daily walk, monitoring your weight, and including an array of fresh fruits and vegetables in your diet.

pauly: I’m a 58-year-old male with Afib for a year. It is controlled well with propafenone, I don’t seem to go into Afib anymore. But I frequently have heart flutter, and my heart beat feels like it is pounding at times, even waking me at night, although BP is good. Should I take further steps to investigate?

Walid Saliba, MD: You might be having episodes of atrial fibrillation/flutter at night. I would suggest monitoring to evaluate your symptoms with possible need to change medications or consider ablation if it becomes frequent.

Sikos: For the past month I’ve been working out a lot (running, body building) and following a healthy diet. I’ve lost weight. My blood pressure is 95/59. My resting heart beat is around 55. My weight is 73kg. I wanted to ask if it’s normal to have this low heart rate beat and low blood pressure. I’m feeling lightheaded, tired and shortness of breath sometimes. Should I be worried??

David Van Wagoner, PhD: Are you taking any medications? Exercise can increase vagal nerve activity that slows resting heart rate. Vagal nerve activity can dramatically slow heart rate and sometimes trigger a light-headed episode or fainting. It may be helpful to consult your cardiologist.

Diva/Lexi: I am a 79-year-old who has had Afib for about eight years. I am totally paced with a pacemaker/defib. I have had two unsuccessful ablations, 4-way by-pass, heart attack and congestive heart failure. I feel good but have a fairly limited exertion level, which I would like to improve along with returning to sinus rhythm. I am wondering if there is any treatment on the horizon that might accomplish this?

Walid Saliba, MD: There is nothing definitely new as far as your Afib is concerned, however, your symptoms may be related to other factors such as your programming of your pacemaker, optimizing your heart failure medications, all of which would require careful evaluation in a specialized cardiology clinic.

Lifestyle and Atrial Fibrillation

Lewbu: I would be interested in hearing about the role of diet, nutrition and dietary supplements in dealing with Afib. Thanks. Lew

David Van Wagoner, PhD: Diet and fitness are important considerations. Recent studies have shown that efforts to control weight and improve fitness can reduce both the “triggers” of AF, and the duration of AF episodes once they occur. Studies in a group of patients with a BMI>30 who underwent a structured weight loss and fitness program have seen a very significant benefit with a loss of ~10% of body weight. With respect to specific dietary advice, reducing sugar intake is important as diabetes and obesity are significant risk factors for AF. There is no solid evidence for dietary supplements as effective treatment for AF.

rock: I was told by my cardiologist that I cannot run anymore marathons. Too stressful for the heart. Agreed? I ran Chicago in 2015, and in 2016 I have Afib. I ran the Chicago marathon in 2015 and did not have Afib. In 2016 I got Afib. I’m 61 and under doctors care. My Afib is under control right now as a result of new meds. Can I run another marathon? Or am I relegated to shorter runs?

Walid Saliba, MD: There is usually no restrictions to exercise as long as your atrial fibrillation is under good control and as long as you are not in atrial fibrillation with fast heart rate at the time of your exercise.

northwoods10: OK to exercise strongly with persistent Atrial Flutter? Always in it.

Walid Saliba, MD: As long as you take medications to effectively control your heart rate.

Renice: There was a study done regarding Afib and weight loss. Has this proven to be true beyond the study?

David Van Wagoner, PhD: Yes, there is a growing body of literature to support the beneficial impact of weight loss on risk of AF. These articles provides a useful summary of the role of modifiable risk factors as targets for AF prevention: 

millAfib: If my Paroxysmal Afib is well controlled, is it a risk to have a little coffee and occasional coke or tea?

Walid Saliba, MD: You will be the judge – not all patients have similar triggers.

Triggers of Atrial Fibrillation

gassabel: What are known triggers for AF? My AF’s happen between 2 a.m. and 4 a.m. during sleeping hours, coincidently today at 4 a.m. Until today, I thought it was due to heat which blew that theory. My temp was 93.5. I’ve had this for 24 years. Four episodes avg. per year. Thank you.

David Van Wagoner, PhD: It is not uncommon for AF to occur at night. The nerves that control the heart rate are typically in the “sleep mode”, and resting heart rate drops. Under these conditions, pacemaker activity from areas other than the normal pacemaker in the heart can trigger the onset of AF. In addition, many patients with AF have an underlying issue of obstructive or central sleep apnea. If you are frequently sleepy during the daytime, that is especially likely to be the case. Treatment of sleep apnea with CPAP or other devices can sometimes help to reduce the frequency and burden of AF.

Fibman: What are known triggers of AF? And is there any medication that can be taken after Afib starts to reduce the duration of the episode?

Walid Saliba, MD: Different people have different triggers. These can include alcohol, caffeine, stress. The pill in the pocket approach involve taking an antiarrhythmic medication (flecainide) to reduce the duration of the episode. However, not everyone is candidate for this approach – an evaluation is needed prior to prescribing it.

Atrial Fibrillation

Runfoyrun: Is there any significant difference in the cause of Afib when there is a slow ventricular rate vs. a rapid ventricular rate? I had slow Afib before RF ablation and one document episode of rapid Afib post ablation.

Oussama Wazni, MD: No. There is no difference.

Scroak7: 67, athletic, 173 lbs., mild hemophilia A (28%), permanent Afib since August, good echo, no sleep apnea, VO2 max 63% starting at 90 bmp quickly up to 150 and staying there performing well. metoprolol doubled to 50 mg twice daily but tired me. Halved the metoprolol added 125 mg Diltiazem and self-converted a week later to 55-60 bmp with a hard exercise max about 100 bpm. Beautiful. Afib returned a week and a half later, almost with a vengeance but not really just disappointingly. Paleo diet including dairy, less than moderate alcohol, supplements including cod liver oil, K2, B12, D3, Magnesium, Glucosamine- Chondroitin, and Milk Thistle. What can I do or not do that might make a difference? Mayo Clinic Phoenix, where I went for a second opinion and have happily stayed, recommended a conservative approach based on few if any symptoms after arrhythmia specialists were steering me towards an ablation, hematologists recommending Eliquis and little if any factor 8.

Oussama Wazni, MD: If you feel that the atrial fibrillation is having a negative impact on your quality of life, then a rhythm control strategy should be pursued. This can be achieved with antiarrhythmic medications, or an ablation. If, however, you feel that your symptoms are minimal, then current management is probably adequate.

rainbow78: My son-in-law, who is otherwise healthy and his heart shows no other issues, but he had pneumonia and went into Afib for three years. He had Cardioversion 1 1/2 years ago and went into rhythm. He had another bout of pneumonia and went out of rhythm two months ago. The medical Cardioversion was tried but did not work, so he underwent another successful Cardioversion two weeks ago. Unfortunately, this week he experienced severe pain from a kidney stone and it was blasted to remove. After the procedure, he went back into Afib. What would you recommend at this point?

David Van Wagoner, PhD: There is a rather strong relationship between systemic inflammation and AF. Pneumonia is an infection that has a profound impact both on lung function and systemic inflammation, and it is not uncommon for either pneumonia or chronic lung disease to cause AF. Similarly, the kidney stone procedures (and any surgical procedure) can increase systemic inflammation and may trigger transient episodes of AF. Once the inflammatory episodes resolve, AF frequently resolves as well. If lung problems persist, AF risk remains elevated.

Harry H: Does HIS — Bundle pacing reduce or improve Afib?

Walid Saliba, MD: We do not have any evidence for this.

hccuabsatx: I had an ascending aortic aneurysm resection with Dacron graft and aortic valve reconstruction in autumn 2010, and experienced post-surgical Afib for a month or so, even though I was treated with Coumadin for three months post-op. Then it popped up again about two years ago and is currently controlled with Eliquis. Are there any particular issues I should watch for related to that combination of Afib and the surgery? I also have cardiomegaly, a first degree atrioventricular block, essential hypertension controlled by meds and hyperlipidemia controlled by meds.

Oussama Wazni, MD: No. Post-op Afib is very common and a significant number of patients go on to develop atrial fibrillation, not related to surgery in the future.

Rick1: I am 77, taking Xarelto, have had paroxsymal atrial fibrillation for four years, and have no symptoms of Afib. What is your opinion of living with permanent Afib versus trying various methods to convert to sinus rhythm?

Oussama Wazni, MD: If you have no symptoms, then there is no reason to try other methods to convert to sinus rhythm.

bw: Hi. How is Afib that is caused by Mitral valve problems different than other causes? Is the treatment different? Thanks Bill

David Van Wagoner, PhD: Mitral valve prolapse (the most common form of mitral valve disease) is a “leaky valve.” This means that when the heart muscle tries to pump blood into the body, some flows backward into the left atrium. The atria normally operate under a very low pressure; this pressure is increased when the valve does not close correctly. The atria expand when the pressure is increased. This causes the left atrium to become enlarged, and this increases risk of persistent AF.

Paroxysmal Atrial Fibrillation

songbird: A 67-year-old female, I’ve had paroxysmal AF for many years, slowly getting more frequent. It is very regular, starting every 4th afternoon and used to last for 48 hrs. Am taking rivaroxaban and 5mg Nebivolol which slowed heart from 85 bpm to 65 but upping to 10mg didn’t help AF nor did flecainide. Then diagnosed pre-diabetic so successfully lost 25 lbs. on low carbs (BMI now 27 and am blood sugar 100) and am taking magnesium supplements (125 x 2). My AF is still every four days, is worse when I am asleep but now only lasts 12 -24 hours. My blood sugar rockets from 100 to 120-130 on days I have the AF. Is this relevant and is it cause or effect? I have been offered oblation but will that help if something else is at work here such as hormones? Is it normal for such a predictable pattern? Alcohol, coffee, chocolate aren’t triggers so what else might be? Any other tests/supplements/medication worth trying before I give in to surgery? Don’t want to take amiodarone – too many side effects.

David Van Wagoner, PhD: That your AF still remains paroxysmal is a good sign. You note that your weight loss efforts have helped to lower your blood sugar. Weight loss and fitness are things that you can do that can significantly impact the frequency and duration of AF episodes. Thus, it may be very helpful for you to consider what else you can do to increase your level of fitness. Helpful goals can include taking a daily walk, modest weight lifting to build muscle mass, and including an array of fresh fruits and vegetables in your diet.

bonhag: I was first diagnosed with Atrial Fibrillation in 2014 when I noticed some “palpitations” and when I was sent to a great cardiologist who suggested a holter monitor even when the stress test was normal. Now I am on xarelto, 20mg and bystolic, 5mg, and I am being followed by a cardiologist. Now, it appears that I am experiencing more episodes of Atrial Fib on a daily basis. Is this normal to see Afib to increase over time? If so, what do I do? I have been told that the risk of stroke with Afib is about 2% (I am 73-year-old male) and with a watchman implant procedure also has a 2% change of stroke during the procedure…and that the mini Maze procedure should only be done if there is other heart issues that should be addressed. What options do I have? Do I stay the course with my current cardiologist? Should I come to Cleveland Clinic for an evaluation? And if so, what would you find? Should I have another Holter monitor now that the frequency has increased? Thanks. Robert

David Van Wagoner, PhD: Yes, it is common for the frequency and duration of paroxysmal (self-stopping) AF episodes to increase with time. There are several less invasive alternatives to the surgical (Watchman or mini-Maze) procedures. These include radiofrequency ablation, typically targeting the pulmonary veins, and a cryoablation, targeting the same area. If you are interested in having a procedure, consulting with an electrophysiologist or surgeon who performs that procedure frequently is one of the best ways to have a good outcome.

adourian: Have been under Dr. Saliba’s care for several years with paroxysmal Afib (10 hr. self-correcting episodes). Have aortic valve stenosis as well. On eliquis at Dr. Saliba’s recommendation. Over that time, have tried to address all known triggers without success and episodes increased in frequency to weekly. Was ready to move to metropolol/flecainide. Since AS diagnosis and the start of Afib I had reduced my exercise program substantially but Dr. Saliba suggested that I wasn’t at risk to go back to running if I wished (I do every other day 3-4 miles) as long as I listened carefully to my body’s feedback. Before medicating I returned to running in October last year and haven’t had an episode since. Does this make any sense? Can exercise reduce PV inflammation? Any basic cellular research results that can point to why?

David Van Wagoner, PhD: Yes, there is very good research showing that efforts to improve fitness improves vascular health, reduces systemic and cellular inflammation, and reduces risk of AF. We applaud and encourage your efforts to maintain fitness and an appropriate weight/diet.

Syll_mase: I visited your clinic in July, as my brother was admitted with cardiac surgery. I am a 68-year-old female and have paroxsymal Afib – once a week – 12-24 hr. duration – for three years. Frequency and duration decreased with low carb diet and weight loss over past three years. I exercise every day – weights two days a week, tai chi two days and walking three days and have always exercised regularly to help me avoid heart issue. I am generally regarded to have good health – except for elevated cholesterol in my family. I was considering a catheter ablation but have heard more Afib surgical ablations such as mini-maze. I was interested in having LAA closure making surgical ablation a more desirable choices. Which doctors at Cleveland Clinic can a contact for additional information? Evaluation, success rates, duration, follow-up, etc.

Walid Saliba, MD: I would be happy to evaluate you for an Afib ablation along with LAA occlusion (if you are a candidate for it). During that visit, you can discuss the option for surgical approach as well with Dr. Soltesz.

jamesp: I was told that a person with proximal Afib has a higher chance of stroke than that of a persistent Afib. Also, ablations have been found to be not effective over time and that all proximal Afib will eventually turn into persistent or permanent a fib eventually.

Walid Saliba, MD: The risk of stroke depends on several factors including HTN, DM and other cardiac abnormalities and not necessarily on paroxysmal vs. persistent. The role of an ablation is to reduce significantly the burden of Afib and should not be considered a cure. In our experience, the recurrence of Afib is around 6% per year after the first year following an ablation.

colo157: I am 72 years old with paroxysmal Afib. Episodes are getting closer together from 6-10 months apart to 2-4 weeks apart. I take Flecainide as needed – two tablets that work. As episodes become constant will medication still work?

Walid Saliba, MD: It seems that your atrial fibrillation is progressing and an ablation is to be considered in this situation.

Persistent and Chronic Atrial Fibrillation

dpcasanta: Greetings. I am 61 years old. I have been an Afib patient for 14 years. The last four years I have been in chronic Afib. I take Xarelto and no other drugs for my condition except a statin. My lifestyle is normal. I work out four to five days a week. My echo shows no abnormal conditions. I recently completed a 24 hour holter monitor test and my cardiologist was pleased. Average heart rate was about 80. My question: Can I ever get to normal rhythm? And if not, how will this chronic condition affect me over the next 10 to 20 years? Is a pacemaker in my future? Thank you very much.

Walid Saliba, MD: You can try to go back to normal rhythm but the fact that you do not have any symptoms during Afib, makes it of questionable value especially that we do not know the long-term effects of Afib on longevity and cardiovascular events as long as you are taking your medication. Pacemaker is not necessarily a solution or a need in your situation. We can attempt to put you in normal rhythm to see if you have any change in your functional capacity and make further recommendations as to long term therapy accordingly.

TClem: I am an 81-year-old man. For the past 15-20 years I have had persistent atrial fibrillation with INR well controlled using warfarin. Other than this I am fully healthy and walk two miles every morning as well as participating in multiple social activities and non-profit organizations. How much of my “oompf” is lost due to Afib and is my life expectancy adversely affected? Should I consider any change in my routine?

Walid Saliba, MD: Do not change – the answer to your question will not change the management. Continue doing what you are doing!

marika111: Have been in permanent Afib for five years. How does this affect my life expectancy only due to this situation?

Oussama Wazni, MD: There’s no clear indication that lone atrial fibrillation will shorten lifespan significantly.

PeterF: Are there any new recommendations for patients with long standing AF, more than five years, with moderate symptoms? Right now, continuing anticoagulation and rate control. TY Peter F.

Oussama Wazni, MD: Peter, if your symptoms are tolerable, then rate control and anticoagulation is reasonable. However, if you feel that your Afib is affecting your quality of life, one can try tikosyn and if that fails, then consider ablation.

Atrial Flutter

northwoods10: I have been in persistent Atrial Flutter for the past five years. (I usually don’t feel my heart’s rapid beating and I can function normally.) Other than taking Cardizem, is there anything more I can do? Is this reversible?

David Van Wagoner, PhD: First, you should discuss anticoagulation with your cardiologist, as atrial flutter can significantly increase risk of stroke. If you are in atrial flutter rather than atrial fibrillation, there may be a relatively simple ablation procedure that can effectively treat this. Atrial fibrillation sometimes occurs after atrial fibrillation is terminated; in that case, a more complex but often effective pulmonary vein isolation procedure can be done to treat the atrial fibrillation. In either case, you would benefit by contacting an electrophysiologist for an evaluation.

Cardioversion

jvern3: My doctor wants to shock my heart to treat my Afib. What are the risks involved, and also the success rate?

Oussama Wazni, MD: The success rate of cardioversion is 100%. The issue is maintenance of sinus rhythm, which may be short-lived depending on many different factors. If you have symptoms with your Afib and it recurs after your cardioversion, then your doctor may choose to place you on an antiarrhythmic medication. The risks include having a stroke if adequate anticoagulation is not achieved.

Ablation – PVAI

Fla Man: Amiodarone seems to be the only medication that keeps me in sinus rhythm. At least 2 other medications have been tried without success. I’ve been told I’m a good candidate for PVA. My question will I have problems with Medicare and my supplement to have the procedure done? Thank You.

Walid Saliba, MD: This is a good question – we can refer you to our Financial Counselors who are experts in helping solve this issue.

John Z: If I have ablation procedure on a Friday, will I be able to return to my office job on Monday? How many days and nights will I spend in the hospital?

Walid Saliba, MD: You spend one night in the hospital and you should be able to go back to work with a desk job on Monday.

lhsdvm: I’m a 60-year-old female who has had SVT episodes for three years, and I’ve had one episode of AF that required Flecainide to terminate it. Since AF apparently causes cardiac muscle remodeling, and paroxysmal AF tends to get worse over time, and drugs only work long term to prevent episodes for a small percentage of people and have side effects, I am inclined to want to try ablation sooner rather than later. What do you advise, in general, in terms of patient criteria for trying ablation?

Walid Saliba, MD: Since you are having frequent episodes, I think an ablation is a reasonable option to consider.

Bill1950: What is the different reasons for a cryoablation vs. catheter ablation?

David Van Wagoner, PhD: These are different techniques that address the same goal – to isolate spontaneous activity originating in the pulmonary vein (PV) region from colliding with the normal activity that initiates and conducts the heartbeat. The radiofrequency ablation procedure uses many brief episodes of heating the atrial muscle to isolate the PVs. Cryoablation uses freezing rather than heating to accomplish this goal. Both approaches have shown similar efficacy, and are more effective in patients with paroxysmal episodes of AF than persistent AF.

DTVallas: How does an enlarged left atrium impact the success/outcome of an ablation procedure to the left atrium?

Walid Saliba, MD: The bigger the left atrium the higher the chance of having scarring in the left atrium which would affect the outcome of the procedure.

Ron W: I have had PAF for approximately 50 years. I have been cardioverted twice within the last two years. When is ablation the best answer? I currently carry flecanide with me but do not take it unless I’m in Afib. I do take metoprolol 100 QD. Also is propafenone a better drug than flecanide for my setting?

Walid Saliba, MD: Flecainide and propafenone are fairly similar. You should consider ablation when your episodes becomes frequent enough to affect your quality of life and raise your frustration level. We believe that early intervention with ablation might improve the longer term outcome.

amor74: AF diagnosed 2011, cardioverted on day diagnosed. (Paroxysmal AF) I have an ablation planned soon with some reluctance about my decision. On flecainide 200 day and Cardizem 120 day plus two anti- hypertensive meds. AF breakthroughs more frequent now (last one Jan.13 2017). EKG Jan 2017: Sinus Bradycardia, Nonspecific QRS widening, QT 456, QTcH 442, QRSD 114, P-QRS-T, 23/-11/24. No symptoms excepting extreme anxiety when I have an episode. No SOB, no dizziness, no fainting, no chest discomfort, nothing. Echocardiogram Jan 2017: normal Lt vent size (EF 64%), mild concentric Lt vent hypertrophy, grade 1 diastolic dysfunction, normal Rt vent size + function, mild left atrial enlargement, mild regurgitation, mild pulmonary hypertension. Rt vent systolic pressure est at 41 mmhg (increase 24 mmhg from June 2015 echo). I am fearful of having an ablation and had hoped to wait until the CABANA results are completed. Have I decided correctly to undergo the ablation? Respectfully, Elaine

Walid Saliba, MD: Afib ablation is indicated for symptom relief and is based on a patient’s choices and wishes. Therefore, the decision is up to you, depending on how much Afib is affecting your quality of life.

Mackadoo: Is there any advantage of having an atrial ablation in a patient with minor symptoms? My EP states repeat procedure is often needed and the ablation doesn’t decrease the risk of stroke. My symptoms are mild fatigue and SOB with distance walking or exertion. HR averages 80 at rest. Normal HR in sinus rhythm is 55. Afib is chronic four years post-op open heart valve repair with ring at CCF. Rythmol and cardioversion successful for two years.

Oussama Wazni, MD: The decision to proceed with an ablation depends on your perception of your symptoms. If you feel that the symptoms are affecting your quality of life, then an ablation is reasonable. On the other hand, if you feel that the symptoms are tolerable, then you may want to consider deferring an ablation.

waynejohnd: I was first diagnosed with Afib in 2001. My cardiologist converted me to sinus rhythm using several medications including amiodarone. I converted two hours after the IV started. The only medication he prescribed when I left the hospital was topral. Several years later I went into Afib again. An electrophysiologist was called in. He changed my medication to sotalol. In the course of the conversation, he felt I was a good candidate for pulmonary vein ablation. However in time I went back into Afib. While in the hospital they tried to convert me with rhythmol, which did not work. Again they used amiodarone, and in time I went back to sinus rhythm. From then on I have been taking amiodarone. I understand insurance and medicare is sometimes reluctant to authorize the PVA due to the cost. However over time I’m concerned over the possible toxic effects of amiodarone. Since two other medications did not help, would I have a problem getting approval for PVA?

Oussama Wazni, MD: No. Getting approval for Afib ablation is currently not an issue.

John Zervas: In 2005, my aorta measured 4.2 centimeters. 2016, my aneurysm measured 5.0 centimeters. I had my aorta and aortic valve replaced a year ago. Prior to surgery no Afib. Four days after surgery, Afib started. My BP is 100/60, resting pulse 55. The past nine months the only time I develop Afib is when I am doing cardio. Will ablation work for me?

Walid Saliba, MD: If you are having frequent episodes of atrial fibrillation, then ablation is an option as well as the option of antiarrhythmic medications.

pendleton: I am a 76-year-old male with constant Afib. I have shortness of breath regularly and am tired often. I had one ablation which was not successful. I have recently learned of success with LAA isolation. What people are candidates for an LAA isolation? Is an LAA isolation procedure performed at Cleveland Clinic?

Walid Saliba, MD: LAA isolation is performed as part of an Afib ablation when it is appropriate. This does not mean that LAA isolation would necessarily lead to better outcome in your situation unless mapping during the procedure suggests so. Usually the reason of the prior failure is the result of reconnection of the already treated veins. We would be happy to evaluate you.

irishcurls: Is there any alternative ways other than meds to keep from having future Afib episodes?

Oussama Wazni, MD: Yes, ablation is an option to avoid medical treatment or in case of failure of medical therapy.

DTVallas: Does an enlarged left atrium affect the success rate of left cardiac ablation?

David Van Wagoner, PhD: Yes. Atrial fibrillation risk and persistence are both increased when the left atrium is enlarged. The reason for this is that part of the pathophysiology of AF is based reentry – circular electrical activity that keeps the atria fibrillating. With larger the atrial size, it is more likely that the fibrillatory activity will persist.

DeanneS: I am scheduled for an ablation on March 15 for my Afib. Have had six – seven Cardioversions since February 2013. The Cardioversion did not work (shocked twice). Was in constant Afib for over three weeks. I am one of the people who do not respond well to being in Afib, very symptomatic. So am having ablation. I have some questions whether the procedure could affect my other heart problems. I haven’t been able to find any info on patients who have both Afib and Coronary Microvascular Disease and Coronary Artery Spasms, and if there are any concerns with the Ablation. I take 60mg of Imdur twice per day since 2011. Started having Esophageal Spasm around six months ago too. Taking Ranitidine for them now.

Walid Saliba, MD: The procedure itself should not affect your other cardiac and esophageal problems. Should spasm occur during the procedure, it is readily recognized and treated.

Repeat Ablation

Treas: If a FIRM ablation procedure is not successful in reducing Paroxysmal Afib events the first time it is performed, does data indicate if it is worth trying a second time?

David Van Wagoner, PhD: Recent studies from independent groups using the FIRM ablation techniques have not had impressive results. While a repeat procedure may be helpful, use of more validated protocols may be warranted.

Momita3: I have had Afib for four years and have had two ablations. I have broken through flecainde and sotalol, failed a tikosyn trial and am currently on amiodarone. My EP says I have a lot of fibrosis and does not want to try another ablation. Amiodarone side effects scare me, I have been on it for 16 months. What are my options?

Oussama Wazni, MD: Your options at this point are 1) continue on amiodorone with periodic surveillance for side effects. 2) rate control and anticoagulation only. This approach allows you to stop taking amiodorone. 3) consideration for a surgical maze procedure if you think that your symptoms warrant such an approach.

pendleton: I have an ICD which was implanted in April 2015. I was put on Sotalol and Eliquis and was fine until October 2016 when I did not feel well. A pacemaker check showed I was in constant Afib. I had a cardioversion in November 2016 which removed the Afib but only for three days. I had an ablation in January 2017. It was unsuccessful in removing the Afib. In another effort to remove the Afib, I was hospitalized, weaned off Sotalol, and put on Tikosyn and Metoprolol. I had two additional cardioversions which were not successful. During the hospitalization, my ICD went off due to a rapid heartbeat. Interestingly this shock put me back in sinus rhythm – but only for three days. Recently, I have read about something called a Left Atrium Appendage Isolation which has been successful in eliminating Afib for some patients. Can you explain this procedure? Is this procedure performed at Cleveland Clinic? Would I be a candidate for this type of procedure?

Oussama Wazni, MD: We usually would not recommend left atrial appendage ablation after one failed Afib ablation. We, at this point, would recommend a redo ablation at Cleveland Clinic and if needed, a left atrial appendage ablation can be performed.

Maze Procedure

magilla: I will be 71 in March, and haven’t had any physical limitations to date as I work five times a week for two hrs. each day doing cardio, circuits and free weights. In the past. What is known: Aortic Bicuspid Leaves stenotic-0pening is at .75cm gradient at 25, mitral valve moderate, Tricuspid moderately severe. Aortic Aneurysm 4.5 stable for several years. Arrhythmia for many years mostly Afib. Cardioversion worked temporarily. Edema present for several years. Systolic BP on increase. Five day average 138/70. Pulse generally runs between 35 and 40 BPM. Recently trending down.

Recent symptoms indicate a procedure is imminent. Symptoms- some light headedness, tire during real strenuous activity such as sawing large logs by hand.
1. If I have a choice on order of procedure to correct problems as outlined what would you recommend?
2. How successful is Ablation for Afib?
3. What percentage of patients with my condition have to have a pacemaker?
4. What is mortality associated with MAZE?

Walid Saliba, MD: You have concomitant cardiac problems (heart valves) that will need to be addressed in conjunction with the atrial fibrillation. You will need to have a full cardiac workup to determine the best approach for your condition be it Afib ablation or valve surgery along with MAZE surgery. In view of your already low heartbeat, evaluation for possible pacemaker is reasonable.

wfoust: My husband has rheumatic heart valve disease and began having A Fib symptoms over a year ago. He has been hospitalized twice (once with cardioversion) and also two ER visits for treatment to bring him back into normal sinus rhythm. The last ER visit was successful in bringing his heart rate down, but he remained in A Fib/A Flutter for another three days before it subsided. He still goes into A Fib for several days at a time, creating much shortness of breath with any exertion at all. He is on Sotalol, 160 mg twice per day. Last week he was referred to Cleveland Clinic for mitral valve replacement. Once his mitral valve is replaced, will the A Fib go away, or will he need to have procedures done to eliminate/reduce the A Fib symptoms?

Walid Saliba, MD: The surgeons can do a MAZE procedure along with his valve surgery to treat his atrial fibrillation.

Medications: Anti-Arrhythmics

Unionjack: I have Afib that is managed quite well on medications. Are there any draw backs for delaying ablation surgery as recommended by my Cardiologist?

Walid Saliba, MD: The purpose of treating Afib is to improve symptoms. If you are doing well on medications without side effects then it is reasonable to continue that route (as long as you are not having increased frequency of silent episodes, which can be checked for with monitoring).

TymTrvlr1: Afib paroxysmal patient for six years. Had frequent attacks of tachycardia until ordered by my cardio to reduce intake of beta blocker. Yes, reduce intake. After five years, the higher dose of beta blocker I was prescribed appears to have been initiating frequent ping/pong attacks of high heart rates and low heart rates. Reducing dosage of the beta blocker reduced (eliminated) that frequency of attacks and leveled me off to between 60 and 65 bpm, exactly where I want to be. However, now my attacks of high heart rates seem to recur in 9 to 10 days, then convert overnight. The probable 9 to 10 days is becoming predictable. Has anyone in the forum had the same experience with a dosage change and/or the cycled occurrences of Afib I am now experiencing?

Oussama Wazni, MD: No. I am not aware of any experience where my people have lower heart rate with decreased dosage of beta blockers, however, atrial fibrillation can be cyclical and have a pattern similar to what you’re describing.

SMDTS: I’ve been taking tikosyn since 2008. This year I was told I needed to have an EKG and a creatinine check every 3 months. Is this something new with this medication? Or with my long term use? I tried numerous medications prior to tikosyn such as amiodarone and rhythmol with bad results. Are there new anti-arrhythmic medications on the market?

Oussama Wazni, MD: No. This is not something new and has always been part of the usual care for patients taking tikosyn. There are no new antiarrhythmic medications currently.

rodgerf: Is there a typical time period that Tikosyn remains effective before kidney issues dictate cessation of use?

Walid Saliba, MD: Not really – as long as renal function is normal, you can continue taking tikosyn with regular follow up and as long as it is keeping you in normal rhythm. Tikosyn does not damage the kidneys but if kidney function is affected for some reason or another then the tikosyn dose should be adjusted.

roadkinglarry: I am being treated with Carvedilol 12.5 twice a day. It has brought the extra beats about 80% and my doctor wants to increase it more. This drug has side effects and I would like to be off the Carvedilol. I met with his Electrophysiologist who says he can operate entering through the groin with a 90% + success rate. Would you advise surgery or to stay with the drugs.

Walid Saliba, MD: If you have side effects of the medication, considering the ablation procedure is reasonable. This will get you off the medication without the nuisance side effects.

Maile: I was diagnosed with Afib last June. After two cardioversions (neither of which successfully kept me Afib free longer than two weeks), I was given Tikosyn after 3rd Cardioversion last August. Together with Eliquis I have been Afib free since then. My question is: How long is it safe to stay on this regimen? Should I explore other options or just be happy I am Afib free? Thank you for considering my question!

Walid Saliba, MD: You can stay on this medication as long as it is keeping you in normal rhythm and as long as you get regular blood checks for kidney function, K, Magnesium as indicated by your physician. Be happy and enjoy normal rhythm!

Punkypoo: Should you immediately be put on amiodorone for Afib not using any prior meds.

David Van Wagoner, PhD: Amiodarone is often given for a few weeks after cardiac surgery to help prevent postoperative AF. Long-term use of amiodarone is somewhat problematic as it can cause lung and/or skin problems. Thus, amiodarone is not usually initiated as a first line therapy.

CanadianAfibber: Is atenolol a treatment of Afib with cardiomyopathy? Should somebody with a history of Afib and cardiopathy being doing strenuous activity?

Walid Saliba, MD: Atenolol does not prevent Afib; it decreases the heart rate in response to Afib to reduce symptoms. Usually symptoms limited activity is recommended for patients with cardiomyopathy with special care to control the ventricular rate during the episodes of atrial fibrillation.

irishcurls: I had my first and only Afib episode in November. Is it necessary to stay on a beta or channel blocker for the rest of your life? I don’t like the way these medicines play with my blood pressure and I’ve never had blood pressure issues before that required meds.

David Van Wagoner, PhD: The greatest concern with AF is the associated risk of stroke. If a Holter monitor or longer-term monitor shows no signs of AF, your doctor may conclude that medications are not needed. It is important keep your blood pressure in a healthy range. There are good alternatives to beta blockers for maintaining blood pressure with fewer side effects. Please ask your doctor to discuss these, or find a second opinion.

carmencicero: I had a triple bypass in 2003 and two unsuccessful ablations. A pacemaker was installed 3 years ago and has been a great help as my heart rate was slow and causing fainting. The doctors describes my Afib as mild but I have irregular heartbeats for 8-12 hours which are debilitating. My physicians, when asked, can try Tikosyn–which they say are used at Cleveland Clinic. I am fearful of drugs because I have had bad reactions. How successful is this drug and how well tolerated it is?

Walid Saliba, MD: The success rate of this medication is around 60% at one year; but varies from patient to patient. It requires a 3 day hospitalization to start the medication. We do use this medication routinely. A small number of patients are not deemed good candidates and this is evaluated during their hospital stay.

stressless: My husband had a triple bypass in 2003. He has what the doctors say is a mild case of AF, which lasts a few seconds to a minute or more (about 4% of his life). He has had two unsuccessful ablations within the past four years and had a pacemaker installed. He is on Alprazolam (0.25mg), Metoprolol (12.5 mg), Pravastatin (10 mg), Tamsulosin (0.4 mg), Xarelto (20 mg). His major health complaints are irregular heartbeats (with some AF events), which now occur 2X per week and last 2 to 8 hours on average. During these periods, he feels tired and sick to his stomach and usually takes a tranquilizer and rests or goes to bed. My husband is considering taking Tikosyn and going to the hospital for 3 days while he is monitored. How successful is this drug and is it easily tolerated?

Oussama Wazni, MD: Yes, tikosyn is very well tolerated. It is successful in maintaining sinus rhythm at the one-year mark in 60-70% of patients.

Renice: I have tried two medications: Sotalol and flecainide. Both have resulted in a reaction of long pauses for no reason. I am afraid to try any other med. Is ablation the only other remedy left for me?

Oussama Wazni, MD: There are a few more medications that can be tried, however, based on what you’re telling us, these are unlikely to be successful or without side effects. As such, an ablation seems reasonable.

GACBlack: What do you think is the best drug for those of us who have intermittent AF? Are there beta blockers that don’t make you tired? Do you think Eliquis is safe for migraine sufferers? Do you believe AF causes ocular migraines with visual aura? Thank you

Walid Saliba, MD: Choice of drug depends on the underlying cardiac condition. If there is no heart disease, flecainide is a good medication to start. This should be taken in conjunction with beta blockers, which unfortunately can make some patients tired. An ablation might eliminate the need to take medications. Eliquis is safe in migraine sufferers. I do not think that Afib causes ocular migraine but some triggers of ocular migraine might also be triggers for Afib; at the level of the central nervous system.

Blood Thinners, Anticoagulation, and Left Atrial Appendage (LAA)

WN: I had a successful cryoablation about two years ago. I’m off all heart meds including tikosyn, metoprolol and xarelto. I do not have any other cardiac problems. I’m 67 yrs. old. I feel great. Should I still be on a blood thinner?

Walid Saliba, MD: It seems that your risk of stroke is relatively low (CHADS-VASC1) if you do not have any hypertension, DM, or heart disease then it should be ok to be off anticoagulation.

Danno: I am a 77-year-old male in Afib about 26% of the time. Monitored by my pacemaker. Cannot take anticoagulants due to minor lung condition (bronchiectasis) which caused me to cough up blood. I have had cardio versions and put on different meds but always go back to permanent Afib. Now I am on Tikyson which helps. Cures for Afib all require anticoagulants for a while. I am otherwise in good health and active. What does someone like me do as I worry about strokes?

Walid Saliba, MD: You may be a candidate for left atrial appendage (LAA) occlusion device (WATCHMAN); which has the effect of reducing stroke similar to anticoagulation without the need to take these medications. This is a procedure that we perform at Cleveland Clinic – we would be happy to evaluate you.

misslottie: If one has occasional Afib like once a year do they need blood thinners or can they take baby aspirin? Also can you have Afib and low heart rate at same time and what problem does that pose if heart rate in the 70s?

David Van Wagoner, PhD: The risk of stroke depends on a variety of factors that include fitness level, history of hypertension, heart failure, and diabetes. Age and sex can also impact stroke risk. If you are in good health, under age 65 and have few risk factors, the risk of stroke is relatively low. To be safe, you make wish to contact your cardiologist to determine how frequent AF is; this is because many episodes of AF are not sensed by the individual experiencing them.

felito: I am 74 years old with wolf parkinson white syndrome, is there any new drug replacing warfarin?

Walid Saliba, MD: Yes – there are newer oral anticoagulants that do not require monitoring bloodwork.

ksaglenn: I am a 56-year-old female paroxysmal Afib patient. I have undergone two heart ablations. Approximately 4 weeks after the first one in Dec 2015 (I did not need atrial appendage ablated), I developed intermittent SVTs at times with syncope. I underwent a second ablation (to include atrial appendage) in September 2016 to correct. I have been free of Afib and SVT events since. I will undergo a TEE on Wednesday to make sure I am clot free before being taken off Eliquis. Assuming I am clot free, is there anything to say that once I go off Eliquis, clots would not form thereafter? I know being on blood thinner is not a perfect scenario, but does give me a certain sense of security.

Walid Saliba, MD: Unfortunately we cannot say that clot will not form ever – but the likelihood of clot formation is relatively low in the absence of atrial fibrillation provided you have good contraction of the left atrial appendage, which can be checked for with the TEE.

Bonhag: I am a 73-year-old male who was first diagnosed with Afib after I was feeling palpitations (two years ago). stress test did not reveal anything but after two days with Holter monitoring…Now my cardiologist has me on xarelto and aspirin…but it appears my episodes are more frequent…although I do not have much feeling of palpitations. I read about the procedures you are doing and discussed them with my cardiologist and he tells me that my stroke risk is 2% and is 2% during the actual Watchman procedure…does this make sense? Should I just monitor or what?

Walid Saliba, MD: If you do not have any bleeding contraindication for taking xarelto then it is reasonable to continue on such therapy.

healthy100: I am a male age 70, I have had one episode of AF 3.5 years ago I think brought on by drinking ice cold water. I had trouble seeing out of one eye for about an hour (TIA). I had a cardioversion which was successful and have had no other episodes. I am on 5 mg of Eliquis twice a day and 50 mg of Metoprolol twice a day. I have told that I should continue with these medications indefinitely. Is there any change you would recommend? I check my heart rate while exercising 3-4 times a week and have regular yearly checks ups. Thank you

Oussama Wazni, MD: No, I would not recommend any changes. Once a patient has been diagnosed with a TIA, or stroke, they should remain on oral anticoagulation indefinitely.

Pacemaker

fairgo: I have had Afib plus CAD for 12 years with three failed ablations and rate control drugs to control it which it has till recently. I have two questions: My pulse rate has slowed to as little as 34 BPM over the last two months even after exercise so do i need a pacemaker? A recent Echo showed mild pulmonary Hypertension and an EF of 60 should i be worried?

David Van Wagoner, PhD: A resting heart rate of 34 suggests that a pacemaker may be helpful; you should consult with your cardiologist, and he may refer you to an electrophysiology consult.

fairgo: Hi. For the last six months, my previously permanent Afib has often recorded as NSR even on an Echo. It has been three years since my last Ablation, so the question is how is this possible? Also my pulse rate has been going lower and lower for the last month. Often it doesn’t rise above 48 and is sometimes as low as 38 and the lowest was 24. Of course this makes me lethargic and breathless, do you think i need a pacemaker? I’m on half the beta blocker dose I used to take, so wonder what could be causing this.

David Van Wagoner, PhD: Your intuition is correct. Atrial fibrillation can increase the amount of fibrous tissue in the heart. This can problems with the pacemaker in the heart, and sometimes requires the patient to have a pacemaker to maintain a normal heart rate. It is best to contact an electrophysiologist for an evaluation.

Blood Pressure

rjean: I am a 70-year-old woman who was diagnosis with Afib a year ago. Since then I have had a problem with my blood pressure. I take Labetalol 1200mg. Losartan 100mg. Hydralazine 100mg, and Cardizem 240mg. Can’t seem to get my top number down. Is a blood pressure problem normal for people who suffer with Afib? Thank you.

Oussama Wazni, MD: High blood pressure is usually associated with Atrial Fibrillation. There is no direct causative affect. However, you should work with your doctor to lower the blood pressure to the normal range.

PVCs

Help w/arrhythmias: I have paroxysmal Afib (three ER visits in 2015) and atrial flutter ablation in 2015. 30-day heart monitor twice in 2015 indicated approx. 7500 PVCs per day which made me dizzy and left me tired and exhausted. Currently taking Eliquis and 12 1/2 mg metoprolol twice per day. I feel PVCs only several times per day but when I check with stethoscope I find they occur 2-3 times per minute. My question: could the PVCs be causing damage to my heart?

Oussama Wazni, MD: PVCs may result in lower ejection fraction if they are very frequent usually more than 15-20,000 per day. If, however, you are having less than 10,000 / day, it is unlikely that the heart function will be affected.

Recorder

Corelrn25: What is your opinion regarding the Medtronic Reveal Recorder? Is it worth it? Thanks.

Oussama Wazni, MD: In what respect?

Corelrn25: Is the Medtronic Reveal Recorder worth the money? Is it sensitive enough to pick up Afib episodes? Someone told me that it is now the gold standard to monitor Afib…is that true? My phone app picks up more interference than a heart tracing so I need a better way to know if I am in Afib as I do not know if in Afib symptomatically.

Walid Saliba, MD: The reveal recorder is fairly sensitive to pick up Afib. The question is what you are going to do with the information. There are devices that you can attach to your smart phone that can read your EKG to determine if you are in Afib at that point.

Corelrn25: Thanks Dr. Saliba. What device are you referring to other than the Kardia app that will accurately pick up my EKG? I have not had good luck with the Kardia app.

Walid Saliba, MD: That is correct.

Echo Results

gwendolyn: Last week’s echo showed enlargement at base of heart flow down to 25%. What can be done for this?

David Van Wagoner, PhD: It is unclear exactly what type of measurement you are referring to. If your left ventricular ejection fraction is 25%, your heart is struggling to provide adequate circulation. If you have difficulty walking without getting tired, you should contact a cardiologist.

Conclusion:

Mellanie True Hills: On behalf of the Afib patient community, I’d like to thank Dr. Walid Saliba, Dr. Oussama Wazni, and Dr. David Van Wagoner for answering our questions. We will post the transcript of this chat soon – sign up for our newsletter at StopAfib.org to be notified when it is posted.

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician’s independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.

Please note that the comments above are the opinions of the Cleveland Clinic doctors, and if you quote these opinions elsewhere, please reference the specific doctor whose opinion you are quoting.

Reprinted with the permission of the Cleveland Clinic.

See transcripts of our previous Cleveland Clinic chats: