Atrial Fibrillation
 RESOURCES FOR PATIENTS

CURES FOR ATRIAL FIBRILLATION

    Before discussing any treatments, your first priority if you have A-Fib, is to consult with your doctor about taking a blood thinner like warfarin (Coumadin, Jantoven) or aspirin (Plavix, Ticlid, Ecotrin). Because the upper part of your heart isn't pumping out properly, blood clots can form and travel to your brain causing stroke.  A stroke can cause paralysis, loss of vision, speech, hearing, mental faculties, and can make life miserable. Stroke is often a fate worse than death. (For more detailed info on the risk of an A-Fib stroke, see Odds of Getting an A-Fib Stroke)

    Current treatments for A-Fib are:

MEDICATIONS
     You go to your doctor and he prescribes a medication you've never heard of, that sounds like something from Star Wars. When you have A-Fib, the strange medication names and medical jargon can be confusing and somewhat overwhelming. The purpose of this section is to describe in everyday language the various medications for A-Fib---how they work, how they might affect you.  Hopefully this will give you a basic understanding of the various medications you may be prescribed, so that you can become an intelligent participant in your own healing process.

    In general, don't expect miracles from current medications. To date, the magic pill that will cure your A-Fib probably doesn't exist.⁵

    The three main drug therapy treatment strategies are:
    1) to prevent stroke by the use of blood thinners like warfarin (brand name Coumadin, Jantoven), Lovenox (an anticoagulant taken by injection), Heparin (used in hospitalized patients), and aspirin (Ecotrin, Plavix, Ticlid). Blood thinners reduce but do not totally eliminate the risk of stroke.³⁶ To be effective warfarin must be maintained at a certain level in the blood stream (INR---International Normalized Ratio between 2.0 and 3.0). Significantly above 3.0 you run the risk of having a hemorrhagic (bleeding) stroke. Below 2.0 you are more in danger of having an ischemic (clotting) stroke, the kind that most often occurs in A-Fib (85%⁵⁶).
    In general, aspirin is less effective than warfarin.⁴⁵ (See FAQs question #10 Which is Better---Warfarin or Aspirin?).
    You should also get tested for variations in the CYP2C9 and VKORC1 genes which influence how you respond to warfarin (Coumadin). If your doctor doesn't provide this testing, you may want to think about getting a second opinion. These tests could save you heart problems related to over- and under-dosing of warfarin.
    2)  to control the heart rate (ventricular beats), but leave the heart in A-Fib by what are called "rate control" drugs,¹⁰⁹
    3) to stop the A-Fib and make your heart beat normally by what are called "antiarrhythmic" drugs.

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        RATE CONTROL MEDICATIONS
    Medications used for rate control can be categorized as:
    1.  Calcium-channel blockers such as diltiazem (Cardizem, Tilazem, Cartia XT)  [the generic name of a medication is listed first, the Brand name is in parentheses] and verapamil (Calan, Isoptin). Calcium-channel blockers prevent or slow the flow of calcium ions into smooth muscle cells such as the heart and blood vessels. Calcium-blockers are preferred if you have heart or lung disease. Common side effects are the heart beats too slow and constipation.⁶²
    2. Beta-blockers such as atenolol (Tenormin), metoprolol (Lopressor, Toprol-XL), esmolol HCI (Brevibloc)  propranolol (Inderal), timolol, and pindolol. Beta-blockers "block" the action of adrenaline on beta receptors in the cells of heart muscle. They slow down conduction through the heart and make the AV Node less sensitive to A-Fib impulses. Beta-blockers are better for active or young people, because exercise reduces the effectiveness of Digitalis and Calcium-channel blockers. Common side effects are the heart beats too slow, tiredness and loss of sex-drive.⁶²
    3. Digoxin (a Digitalis compound, brand name Lanoxin, Digitek). Digoxin slows down and controls the heart rate by blocking the electrical conduction between the atria and ventricles. Digoxin is probably the most widely prescribed drug for rate control, but medical authorities consider it the least effective.⁶

    If you are using any of the above rate control drugs, please be advised that you probably will still have A-Fib. Only your lower heart (the ventricles) is controlled. You are still at risk of stroke and must continue taking blood thinners.⁷

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        "ANTIARRHYTHMIC" MEDICATIONS
    In general current "antiarrhythmic" (anti irregular heart rhythm) drugs aren't always effective and tend to have bad side effects such as pulmonary fibrosis and impaired liver function.^8,9,10,55  They also become less effective over time, with approximately half of the patients eventually developing resistance to them.⁵⁵ Many antiarrhythmic drugs require you to be hospitalized for 3-4 days when they are initially administered, in order to monitor you for bad side effects. Some antiarrhythmic meds can have a "pro-arrhythmic" effect on some people (people react differently to medications).
    Antiarrhythmic drugs are grouped in "classes" according to how they work.
    1. Class I are Sodium Channel Blockers which decrease the speed of electrical conduction in the heart muscle.
    2. Class II are Beta-Adrenergic or Beta-Blockers which slow down conduction through the heart and make the AV node less sensitive to A-Fib impulses.
    3. Class III are Potassium Channel Blockers which slow nerve impulses in the heart.
    4. Class IV are Calcium Channel Blockers which prevent or slow the flow of calcium ions into smooth muscle cells such as the heart. This impedes muscle cell contraction, thereby allowing blood vessels to expand and carry more blood and oxygen to tissues.

    Here is a list of the more commonly used antiarrhythmic drugs, based on an article by Dr. R. Falk of the Boston University School of Medicine:¹¹
      Procainamide (Procan SR, Promine, Pronestyl, Procanbid): Slows nerve impulses in the heart and reduces the sensitivity of heart tissue. Not FDA approved for A-Fib. Long-term use associated with lupus. Generally not used as a first-time drug because of bad side effects. Less effective against A-Fib than the other Class 1A drugs Quinidine and Disopyramide.²⁴ (Class 1A drug)
    Quinidine (Quinaglute, Quinidine Glaconate, Quinidex): FDA approved for A-Fib but risk of death increases during long-term use. Generally not used as a first-time drug because of bad side effects such as increasing the heart rate and impairing the heart's pumping efficiency. (Class 1A drug)
    Disopyramide (Norpace): Not FDA approved for A-Fib. Strong negative inotropic effect (heart muscle contractions weakened). Generally not used as a first-time drug. Good for patients with nocturnal or post-prandial (after meals) A-Fib.²⁷ (Class 1A drug)
    Flecainide (Tambocor): Slows nerve impulses in the heart and makes the heart tissue less sensitive. Approved only for paroxysmal (occasional) A-Fib with structurally normal heart. Normally the first drug tried on otherwise healthy patients with new A-Fib. Not recommended after a heart attack or if you have a structural heart disease. (Class 1C drug)
    Propafenone (Rythmol and the newer version Rythmol SR): Same limitations as flecainide. (Class 1C drug)
    Sotalol (Betapace):  Not recommended (conversion from A-Fib to normal rhythm rate is low). (Class II and class III drug)
     Dofetilide (Tikosyn): FDA-approved for conversion and maintenance. (Class III drug)
    Amiodarone (Cordarone): Not FDA-approved for A-Fib. Moderately effective for conversion from A-Fib to normal rhythm, but onset is slow. Good rate slowing in A-Fib. This is usually the last drug tried on patients because of its toxic side effects particularly in the lungs, liver and thyroid. (Class III drug but it also blocks Sodium Channels like a Class I drug.)
    Ibutilide (Corvert): Not for patients with low blood potassium, a prolonged QT interval (slow heart beat), or torsade de pointes (very irregular, fast ventricular heart beats). Usually given intravenously. Effective in electrical cardioversion. Often used in place of Electrocardioversion (33% to 49% success rate) and is generally more effective in cases of Atrial Flutter than in A-Fib.¹⁰⁸ (Class III drug)

    The Class 1 drugs Quinidine, Procainamide, Disopyramide, Flecainide, and Propafenone should probably be avoided if you've had a heart attack or have structural heart disease.  The Class III drugs Amiodarone, Sotatol, Dofetilide, and Azimilide appear to be safer to use if you have structural heart disease.¹² In structurally normal hearts, Class IC drugs (Flecainide and Propafenone) cause less heart rhythm problems and are the least toxic.¹³

"PILL-IN-THE-POCKET" TREATMENT
    Another treatment approach for A-Fib is to take an antiarrhythmic med at the time of an A-Fib attack.
    For example, one person writes that he takes 100 mg of flecainide three times at intervals of twenty minutes when he has an A-Fib attack. This often shortens the time of an A-Fib attack. "It (the Pill-In-The-Pocket treatment) has changed my life in that it reduces my time in A-Fib to usually a couple of hours as opposed to between 12 to 36 hours. It allows me to recover completely in a lot quicker time, because my heart hasn't been going crazy for a day or more. And it also allows me to remain out of hospital, which has been fantastic." ( Leon, E-mail: sandman_oz (at) yahoo.com)
    Another person writes she would take Rythmol 300 mg and Inderal 20 mg, wait three hours, then take Inderal 20 mg, wait three hours, then again start the Rythmol 300 mg and Inderal 20 mg, etc. Although she daily took a 325 mg coated aspirin, during a bout of A-Fib she would also chew an 81 mg baby aspirin. (Marilyn, E-mail: nmshook (at) sbcglobal.net)
    Another treatment strategy is to take lower doses of an antiarrhythmic med on a regular basis, then take a higher dose during an A-Fib attack. However, this strategy doesn't seem to be commonly used.
    At best, the Pill-In-The-Pocket treatment is a stop gap measure rather than a "cure" of A-Fib. (See also in the FAQs section "Is the "Pill-In-The-Pocket" treatment a cure for A-Fib? When should it be used?")
   

CHEMICAL CARDIOVERSION
    Chemical cardioversion is usually done in a hospital. Some combination of the above antiarrhythmic meds are administered intravenously. Doctors monitor you closely for adverse side effects. Chemical cardioversion is often done in combination with Electrical Cardioversion described below.

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ELECTRICAL CARDIOVERSION
    Electrical Cardioversion is a medical term for giving your heart a shock with a defibrillator to synchronize it, to make it beat regularly (in normal sinus rhythm). It is often used in combination with Chemical Cardioversion.
    During Electrical Cardioversion you are anesthetized and are unconscious when you receive the shock. The shock causes signal producing areas of your heart to discharge all at once. This stops all electrical activity in your heart momentarily, hopefully allowing your normal heart rhythm to take over.
   
     Electrical Cardioversion seems to have the best chance of success in recent onset A-Fib. If your A-Fib just started, It may be a momentary aberration that an Electrical Cardioversion may correct.
    Electrical Cardioversion is considered low risk, but it does have a high risk of forming clots and causing stroke,¹⁴ which is why it is important to be taking anticoagulants like warfarin (Coumadin) both before the treatment and in the three to four weeks following treatment.^38,39 What doctors aim for is an INR (International Normalized Ratio) of warfarin in your blood that is between 2.0 and 3.0. You may have to have your blood tested weekly till your doctor determines you are in this range. If your A-Fib is so irregular and rapid that it is life threatening, you may be rushed to an Emergency room and be given the anticoagulant Heparin intravenously before your electrical cardioversion.
    Electrical Cardioversion, often combined with Chemical Cardioversion, is considered a standard, routine, low risk treatment option, particularly for recent onset A-Fib patients. However, sometimes after electrical cardioversion your A-Fib comes right back. "50 to 75 percent of patients eventually develop Atrial Fibrillation again."³²
    Electrical Cardioversion is somewhat traumatic to the body and requires general anesthesia. It's like a mini electrocution. (The Defibrillator paddles, for example, can leave burn marks on the chest.) People with A-Fib often ask, "How often can I be Electrical Cardioverted? Does it ever become counterproductive or dangerous?" Right now we just don't know the answer to this question. (Former Senator and NBA basketball player Bill Bradley had three successful Electrical Cardioversions from 1996-1998 without any apparent ill effects.¹¹²)  

"NATURAL" REMEDIES
    Unfortunately there isn't a lot of hard data available on "natural" or "organic" remedies for A-Fib. Rigorous double-blind studies such as the FDA requires for medications aren't often done on "natural" remedies. That doesn't necessarily mean that some of these remedies aren't effective for A-Fib, but only that the level of proof of their effectiveness is primarily anecdotal and/or observational.
    1. Magnesium and Potassium Supplements. Epsom Salts Bath. There definitely seems to be some studies indicating that maintaining good Magnesium and Potassium levels may help A-Fib. See http://www.bmj.com/cgi/content/full/312/7038/1101/b,  http://ats.ctsnetjournals.org/cgi/content/abstract/79/1/117, and http://www.lef.org/magazine/mag2007/feb2007_report_water_02.htm. (Thanks to Roland Brown for this info.) See also in the PersonalExperiences section Epsom Salts Cure.
    (One person E-mailed me that he takes 3 grams of magnesium oxide in divided doses per day which seems to stop his A-Fib attacks cold, though this may cause diarrhea.) (Ian from Australia writes that he drinks a lot of water and eats two bananas which reduces the duration of his A-Fib attacks. He stresses that holding on before going to the bathroom is important---it is not only the bananas, but the wave of relief from finally going which can terminate the A-Fib attack.)
    2. Acupuncture, Acupressure. (This author believes that Acupuncture may some day help control A-Fib. Unfortunately he is not currently aware of doctors or studies specializing in Acupuncture for A-Fib.)
    The following remedies may provide temporary relief from A-Fib attacks, but aren't likely to be a permanent cure, or they may not work at all for your A-Fib. Try them at your discretion.
    3. Moderate exercise. For some types of A-Fib, moderate exercise may sometimes bring you out of an A-Fib attack. For others, exercise may trigger or increase an A-Fib attack. (The author, when he had A-Fib, used to wear a heart rate monitor for runners---Polar, Acumen, Garmin, Nike, Cardiosport, Timex, etc.---when he jogged. But all too often the jogging would trigger or make the A-Fib worse, and he'd have to walk back home.)
    4. Deep breathing and holding one's breath while pressing down hard on the diaphragm.
    5. Putting cold compresses or ice on the back of one's neck.
    6. Laying down and trying to relax in a darkened room.
    7. Putting one's head between one's legs and deep breathing.
    8. Vitamins and supplements that seem particularly helpful to the heart are: Taurine, Coenzyme Q-10, L-Carnitine, and Fish Oil. But be advised that, once areas of the heart start generating A-Fib signals, it is very hard to turn them off again. Vitamins and supplements may improve overall heart health and thereby help A-Fib, but they aren't generally considered "A-Fib specific" like some medications.
    (The author hopes to expand this list as more info becomes available and welcomes input and tips from readers. Go to Feedback. See also http://www.lammd.com/
A3R_brief_in_doc_format/lone_atrial_fib.cfm#LAFPreventionProtocol
 11 strategies to prevent Lone Atrial Fibrillation by Dr. Lam.)

ABLATION OR MODIFICATION OF THE ATRIOVENTRICULAR (AV) NODE AND IMPLANTING A PACEMAKER
    From a patient's point of view, this is a procedure of last resort. Each heartbeat normally starts in the right atrium where a specialized group of cells called the sinus node generates an electrical signal that travels down a single electrical road (the Atrioventricular [AV] Node) that connects the atria to the ventricles below. By ablating or eliminating this AV Node, your Atrial Fibrillation signals can't get to the ventricles which does stop your heart from racing. But for your heart to beat at all or at the proper rate, you must have a permanent pacemaker implanted in your heart for the rest of your life.
    What's worse, you still have A-Fib and have to forever take anticoagulants to prevent stroke. Also, patients with Paroxysmal (occasional) A-Fib often develop permanent A-Fib after an AV Node Ablation.⁷⁸ In addition, when you eliminate the AV Node, there is a risk of sudden death because of the ventricles beating too fast.¹⁵ Another factor to be aware of is A-Fib over time may decrease mental abilities and lead to dementia⁹⁸ (See A-Fib Decreases Mental Abilities.)
    If you have a bad Sinus Node and would need a pacemaker anyway, this procedure might work for you.

THE COX MAZE SURGICAL OPERATION 
    In this open heart operation the surgeon makes numerous incisions in your atria. This "maze" of incisions divides your atria into electrically isolated segments, thereby blocking the electrical impulses that cause A-Fib from spreading throughout the heart. The atria continue to be activated by a regular signal from the sinus node. The left atrial appendage is usually removed during this operation.
    The Maze operation does work and has a high success rate; but it hasn't been used often because of the risks of open heart surgery, the danger of bleeding from the incisions, the pain, discomfort and prolonged convalescence from the operation, and the resulting reduced atrial function due to the incisions. However, if you have to undergo open heart surgery for another heart problem, you may want to go to a heart center that can perform the Maze operation at the same time.
    In newer Cox maze operations (such as the Wolf Mini Maze or Saltman Microwave Mini Maze) surgeons do not crack open the breastbone and stop the heart, but instead make small incisions in the chest to access the heart. They use tiny video cameras and even robotics to make the maze incisions. (See Advances in Surgical Therapy for A-Fib for a more in depth discussion of surgery for A-Fib.)
    In the Saltman "thoracoscopic microwave ablation," the surgeons do not crack open the breastbone and stop the heart while putting the patient on a heart-lung machine as in the Cox Maze operation. Instead the surgeons cut keyhole-sized incisions on the sides of the chest to gain access to the heart. Using a tiny video camera the surgeons loop a catheter around the outside of the heart. Each lung is temporarily deflated in turn to allow the catheters to be threaded around the pulmonary veins. The ablation catheters create ±10 microwave lesions around the atrium that will scar and block the electrical impulses causing the irregular heart beat.⁶⁴
    A Catheter Maze procedure has been developed, but currently when it's performed on the left atrium there is a significant risk of stroke with current ablation equipment.⁵³
   

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PERMANENT PACEMAKER THERAPY
    A pacemaker is a small device that sends electrical impulses to the heart muscle to maintain a regular heart rate. Implanting a pacemaker seems to be most helpful if you have a slow heart rate as a result of taking A-Fib medications. Also, a pacemaker that paces the atria may prevent recurrence of A-Fib in up to 20% of patients. (But see Gold for a more critical appraisal of pacemaker therapy.) However, a pacemaker usually isn't implanted unless your heart rate is too slow¹⁶ or you have Sinus Node and/or Atrioventricular (AV) Node problems. But be advised that pacemakers tend to have bad effects over the long term, "...a long-term morbidity (is) associated with a pacemaker."⁸⁰

IMPLANTABLE DEFIBRILLATOR
    Having a defibrillator implanted in your heart is, from the point of view of most patients, not a probable option. A defibrillator shock is painful, like being "kicked in the chest." Most people would rather have A-Fib than be shocked throughout the day and night. Also, it does not address the underlying problem or condition of your heart that causes your A-Fib.

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PULMONARY VEIN ABLATION (ISOLATION)
    We've saved the best for last. Current Pulmonary Vein  Ablation (Isolation) techniques are achieving success rates of 85% in curing Paroxysmal A-Fib with low risk.^17,33,34,41 (Check with your particular heart center for its success rate.) "Curing" A-Fib is defined as restoring patients to normal sinus rhythm without dependence on any medications.⁴¹ (The other 15%, though not "cured" of A-Fib, may be significantly improved after an ablation. They may have fewer or less intense attacks of A-Fib. Medications that didn't work before may now control the A-Fib. But for some there may not be any noticeable improvement at all.)

     Pulmonary Vein Ablation (Isolation) is currently the best technique available for curing A-Fib.^18,19,20

    During Pulmonary Vein Ablation a soft, thin, flexible tube with an electrode at the tip is inserted through a large vein or artery in your groin and moved into your heart. This catheter is directed to the precise location(s) in your heart that are producing your A-Fib. These points are burned off or isolated from your heart. This is a relatively new procedure. (The first journal published report of a successful catheter ablation for A-Fib in humans was done in 1994 in Bordeaux, France.²¹ The first published studies of Focal Ablation [Pulmonary Vein Ablation] within the Pulmonary Veins came from Bordeaux⁴⁷ and Taipei.⁴⁸) Currently, many heart centers in the U.S. are doing Pulmonary Vein Ablation of A-Fib on a regular basis. (For a partial list of these facilities, see Facilities.)
    This is a relatively painless procedure, because there are no nerve endings in the smooth tissue of the heart and veins. However, someone recently wrote me that they felt a lot of pain from the ablation burns.
    If you are in A-Fib during the Catheter Ablation procedure, it's relatively easy for the doctors to determine where the A-Fib signals are coming from and to ablate (remove) them. However, if you have intermittent A-Fib (Paroxysmal A-Fib), it's harder to pinpoint exactly the source(s) of the A-Fib signals.
    The challenge for doctors is how to locate and eliminate A-Fib signals when the patient is not in A-Fib. Since research has shown that most A-Fib signals come from the openings (ostia) of the four Pulmonary Veins in the left atrium, one technique is to make Circular Radiofrequency (RF) Ablation lines around each pulmonary vein opening (called  "Circumferential" or "Empirical Ablation"). This isolates the pulmonary veins from the rest of the heart and prevents any pulses from these veins from getting into the heart. However, it's difficult to make circular RF lesions and they aren't always successful. (A new experimental technique of circular ablation uses a balloon catheter and ultrasound, laser, and/or cryo (freezing) energy to encircle the vein opening and make the circular lesions.²²)

    A different method of locating and eliminating A-Fib signals (called "Segmental Catheter Ablation") uses Pulmonary Vein Potentials. A potential is an electrical charge or energy---like the battery energy in your car. Even if your car isn't running, you can still measure 12 volts "potential" at the battery. Similarly, in your heart any potential in a pulmonary vein area can be measured and pinpointed, even if you aren't in A-Fib at the time. When the area is ablated, the potential disappears. Like taking the battery out of your car, removing this potential eliminates your A-Fib. As mentioned above, this technique can achieve success rates of 85% with low risk for patients with Paroxysmal A-Fib.^17,34,41 For people with Chronic A-Fib, success rates may not be as good. (See Chronic A-Fib.)
    Instead of ablating inside the Pulmonary Vein Openings which may risk Stenosis, the pathways taken by these A-Fib signals from the Pulmonary Veins are located and ablated outside of the Pulmonary Vein openings. The A-Fib Pulmonary Vein potentials or sources of A-Fib signals are disconnected from the rest of the heart.

    Another procedure for isolating A-Fib signals is called "Anatomically Based Circumferential Pulmonary Vein Ablation" by Dr. Carlo Pappone of Milan, Italy who first developed this technique⁵⁸. It is also called "Left Atrial Ablation" by Dr. Fred Morady of the Un. of Michigan⁶⁰. Instead of concentrating on the Pulmonary Veins and Pulmonary Vein Potentials, the emphasis is on creating blocking lesions in the left atrium similar to "Circumferential" ablation described above. But instead of trying to make continuous, perfect linear lesions, a large diameter catheter at a high wattage is dropped and dragged to make the circular linear lesions. There may be gaps left in these lesions which may result in Atrial Flutter. But over time scar tissue usually closes these gaps (see Morady and Pappone). (At the 2008 Boston A-Fib Symposium Dr. Pappone's presentation showed nearly continuous, perfect linear lesions with very few gaps.) 
 
    Pulmonary Vein Ablation (Isolation) is a low risk procedure³³, but it is not risk free. For a more in depth look at the actual risks involved, see Risks in the FAQs section.

    You've just read through most of the treatment options available to you if you have A-Fib. But to be cured of your A-Fib, you need to find a good doctor. You may want to get in touch with an Electrophysiologist, a doctor who specializes in the electrical activity of the heart and in the diagnosis and treatment of heart rhythm disorders---see Finding A Doctor and Questions For Doctors. The Facilities section includes a partial list of doctors and heart centers currently performing Pulmonary Vein Ablation (Isolation).

DECISIONS
"Which is the best A-Fib treatment option for me?"
    This is a decision only you and your doctor can make. But, depending on the type of A-Fib you have, here are some guidelines which may help you. Listed below are A-Fib conditions as described by people with A-Fib. Click on the kind of A-Fib you have in order to read your possible options.

1. "My A-Fib just started."
    
2. "My A-Fib is occasional (Paroxysmal) with no or mild symptoms (sometimes referred to as "silent' A-Fib)."
    
3. "I have infrequent, short episodes of symptomatic A-Fib."
    
4. "I have Paroxysmal (occasional) A-Fib but am in good health overall."
    
5. "I have Paroxysmal (occasional) A-Fib but also have serious heart and/or other health problems."
    
6. "My A-Fib is Persistent or Chronic (all-the-time)."
    
7. "I have A-Fib but am allergic to Coumadin, Heparin, Lovenox and most blood thinners."
    
8. "I've had two failed left atrium ablations and have tried many different medications."
    

1. "My A-Fib just started." You might be helped by a Electrical Cardioversion and/or Chemical Cardioversion. Doctors can perhaps shock your heart back to beating normally. Antiarrhythmic meds may also be used for several months to train your heart to stay in normal sinus rhythm. Ideally after this treatment, your heart won't go back into A-Fib. But don't delay. This treatment seems to work best in cases of recent onset A-Fib.
    
2. "I have occasional (Paroxysmal) A-Fib with no or mild symptoms (sometimes referred to as "silent' A-Fib)." Doctors may have discovered you had A-Fib during a routine examination, but you weren't aware of anything wrong and feel generally OK.
       Since you've probably had A-Fib for a while, an Electrical Cardioversion may not have as good a chance of getting you back into normal sinus rhythm. But it might be worth trying.
       Another option might be to just live with the A-Fib, since it doesn't seem to affect you very much. You still need to talk with your doctor about whether or not you should be on blood thinners, since with "silent" A-Fib you are at risk of an A-Fib stroke. Your doctor may also prescribe Rate Control medications to make sure your heart doesn't beat too fast.
       However, this option of just living with A-Fib may eventually cause you problems. Over time A-Fib tends to stretch and weaken the heart often leading to other heart problems and heart failure.⁷⁷ An enlarged atrium (approximately over 55 mm) may limit your options. Some centers won't accept patients for a PVA(I) procedure if they have an enlarged heart, because the heart walls have been stretched thin and are easily perforated and burnt through by an RF ablation catheter. Also, A-Fib over time may lead to decreased mental abilities and even dementia, because blood isn't being pumped properly to the brain and other organs (see A-FIB DECREASES MENTAL ABILITIES).
       If you choose this option, it is important to monitor you closely; for example, your atria should be measured periodically to see if they are being stretched and enlarged, and your cognitive abilities should be tracked over time. But you may be able to live for years with occasional "silent" A-Fib episodes which don't progress to anything worse.
       The use of antiarrhythmic medications with their risk of bad side effects may not be justified when your A-Fib is "silent" and infrequent. The same holds for a Pulmonary Vein Ablation (Isolation) procedure. (Many doctors won't perform a PVA(I) on someone relatively A-Fib symptom free.)
    
3. "I have infrequent, short episodes of symptomatic A-Fib." 
       An Electrical Cardioversion might be worth trying, though it generally has the best chance of success with early onset A-Fib.
       The option of just learning to live with your A-Fib may not be acceptable to you, depending on how bad your A-Fib symptoms are. Not only do you have to deal with the A-Fib symptoms, but also with the psychological trauma and fear of knowing an A-Fib attack is always possible.
       Since your A-Fib episodes are relatively infrequent, antiarrhythmic meds may keep your heart in normal sinus rhythm. But watch for bad side effects. There is a fine line between giving your body time to adjust to the antiarrhythmic med, and recognizing that the medication is causing you unacceptable side effects. Some people have had success with flecainide (brand name Tambocor) or the newer meds dofetilide (Tikosyn) and Rhythmol SR.
       Because your symptoms are infrequent, you may have a simpler, more easily fixed type of A-Fib; i.e., your A-Fib may come from only one or two spots in the heart which a Pulmonary Vein Ablation (Isolation) has a good chance of curing. However, many doctors and medical centers are hesitant to perform a PVA(I) on someone with relatively infrequent A-Fib episodes.
    
4.     "I have Paroxysmal (occasional) A-Fib but am in good health overall."  
       An Electrical Cardioversion may be effective for you, though it generally has the best chance of success with early onset A-Fib.
       Antiarrhythmic meds may help in the short term, but they tend to lose their effectiveness over time. In general, don't expect an antiarrhythmic med to be a permanent cure for your A-Fib.
       You have perhaps the best odds of being permanently cured by a Pulmonary Vein Ablation (Isolation) procedure. Doctors may use both Electrical Cardioversion and Chemical Cardioversion during and after a PVA(I) to help the heart stay in normal sinus rhythm.
    
5. "I have Paroxysmal (occasional) A-Fib but also have serious heart and/or other health problems."
       An Electrical Cardioversion may not be an option for you, depending on your other heart and/or health problems.
       The antiarrhythmic Class III drugs Sotatol, Dofetilide, and Azimilide appear to be safer to use if you have structural heart disease.¹² Amiodarone is also a Class III drug, but it often has more serious bad side effects even though it is probably the most effective antiarrhythmic med.
       A PVA(I) can  be very effective; however, you need to prioritize and take care of your most serious heart and health problems first. A successful PVA(I) may improve your overall heart functions (see Left Atrial Function...After Catheter Ablation).
    
6. "I have Persistent or Chronic (all-the-time) A-Fib."
       People with Persistent or Chronic A-Fib often have more than one or two spots in the heart producing A-Fib signals. These A-Fib signal sources often have gotten stronger over time and are less likely to be affected by Electrical Cardioversion. Antiarrhythmic meds may also be less effective.
       Until recently your chances of being cured of Chronic A-Fib by a PVA(I) were less than if you had Paroxysmal (occasional) A-Fib. Doctors have to work harder to find and ablate the many A-Fib signal sources often found in Chronic A-Fib patients. Some centers have rules such as not accepting patients who have had Chronic A-Fib for over a year. However, a recent study by the French Bordeaux group reported a 95% success rate in curing Chronic A-Fib after two ablation procedures.⁹² (See also Strategies for Catheter Ablation of Long-Lasting Persistent Atrial Fibrillation.) If you have Chronic A-Fib, you have to be prepared to have at least two or possibly three ablation procedures.
       People with Chronic long-standing A-Fib were generally thought not to benefit from a Maze operation such as the Radial Maze. But recent developments in the Maze operation offer new hope to Chronic A-Fib-ers.⁹⁷ (See also Cox maze operation for patients with Chronic A-Fib.). The Mini-Maze operations probably aren't a satisfactory option if you have Chronic A