Atrial Fibrillation

FREQUENTLY ASKED QUESTIONS

(A-Fib.com complies with the HONcode standard for trustworthy health information. But the HONcode reviewers indicated that some of the FAQs questions were not sourced/referenced. Please be advised that some of these answers are similar to advice or support columns rather than referenced articles.)
    For those who have visited the FAQs section before, the questions have been re-arranged by topic. The topics are:
    Dealing with an A-Fib attack or diagnosis for the first time
    Coping with A-Fib
    General A-Fib Questions
    Treating or Curing A-Fib
    Medications For A-Fib
    Warfarin (Coumadin)
    Pulmonary Vein Ablation (Isolation) Procedures
    Chronic (Persistent) A-Fib

These first questions deal with the shock of having an A-Fib attack or diagnosis for the first time.

"Around 11:00 pm I was getting ready to go to sleep when my heart started going crazy, like it was trying to jump out of my chest. I panicked and drove to an Emergency room. But by the time I got there, my heart was normal again. What happened to me? How much trouble am I in?"
"Did I cause my Atrial Fibrillation? Am I responsible for getting A-Fib?"
"What caused my A-Fib?"
"Is Atrial Fibrillation a prelude to a heart attack?"
"Can I die from my Atrial Fibrillation?"
"My doctor says I have Atrial Fibrillation. Could it be something else? Should I get a second opinion?"
"Will my A-Fib go away on its own?"

The following questions deal with coping with A-Fib.
"What can I do for my husband (wife) when he (she) has an Atrial Fibrillation episode?"
"My husband's A-Fib is getting worse. When should I call Emergency and/or take him to the hospital? I'm petrified with fear for him. Our doctors say don't worry unless he shows signs of a heart attack or stroke."
"Can I exercise if I have Atrial Fibrillation? Should I exercise? Should I cool my sex life?"
"I have a lot of stress at work. Does this stress cause or trigger my A-Fib?"
"Can I drive my car if I have Atrial Fibrillation?"
"How can I tell when I'm in A-Fib or just having something like indigestion?"
"Is there anything I can do to get out of an A-Fib episode? Is there any way to predict when I'm going to have an A-Fib attack?"
"I have A-Fib. In case of an emergency, should I carry a wallet card or a medical bracelet? What information should I put on it?"
"Is drinking coffee (tea, cokes, other products with caffeine) going to make my A-Fib worse or trigger an A-Fib attack?"
"Is smoking medically prescribed marijuana or using Marinol going to trigger or cause A-Fib?"
"Can excess iron in the blood (Iron Overload Deficiency) cause Atrial Fibrillation? How do I know if I have IOD? What can I do about it?"
"Can too little iron in the blood (Anemia) cause Atrial Fibrillation? What can I do about it?"

General A-Fib questions.
"Why does so much Atrial Fibrillation come from the Pulmonary Vein openings?"
"Is my Atrial Fibrillation genetic? Will my children get A-Fib too?"
"Why do older people get Atrial Fibrillation more than younger people?"
"Is Atrial Fibrillation different from what doctors call Paroxysmal Supraventricular Tachycardia?"
"What is the difference between "Adrenergic" and "Vagal" Atrial Fibrillation? How can I tell which one I have? Does it really matter? Does Pulmonary Vein Ablation (Isolation) work for Adrenergic and/or Vagal A-Fib?"
"I had a single episode of A-Fib and was successfully converted with medication (Cardizem drip). I had only four hours of sleep, had eaten no breakfast, but did have an extra large coffee. I also had watery diarrhea and was somewhat dehydrated. Is it possible that my electrolytes were out of whack and led to the A-Fib episode? I haven't felt any A-Fib symptoms since.
I'm wondering if it's possible to have a single A-Fib attack and not have any others."
"I've had A-fib for several years and have read that it may produce fibrosis and collagen deposits in the atrium (See: A-Fib Induces Fibrosis). How can I determine or measure how much fibrosis I have? Can something non-invasive like a CT scan measure fibrosis?"

The following questions deal with treating or curing A-Fib.

"Is Atrial Fibrillation curable? Or can you only treat or control it?"
"Which is the best A-Fib treatment option for me?" (You may need to read the complete Treatments section of A-Fib.com to familiarize yourself with the various treatment options, if you haven't done so already.)
"Is there a diet I could follow which would cure my A-Fib?"
"Are there exercises that will help eliminate my Atrial Fibrillation?"
"I like my Cardiologist, but he has not talked about me seeing an Electrophysiologist. Should I ask for a second opinion from another Cardiologist?"
"I have a lot of extra beats and palpitations (PVCs and/or PACs) which are very disturbing and frightful. They seem to proceed an A-Fib attack. What can or should I do about them?"
"I have a defective Mitral Valve? Is it causing my A-Fib? Should I have my Mitral Valve fixed first before I have a PVA?"
"I have silent A-Fib (A-Fib without any obvious symptoms). It was discovered by accident when I was getting a physical. Is there any way to tell how often I get A-Fib or how long the episodes last? What kind of A-Fib monitors are available?"
"I've had Paroxysmal (occasional) A-Fib for a couple of months, but the A-Fib episodes seem to be getting longer and more frequent. I'm worried about going into permanent (Chronic) A-Fib which I know is harder to cure. How long do I have before I go into permanent A-Fib?"
"I definitely have A-Flutter and possibly A-Fib as well. They want to do a Flutter-only ablation on me. Will that help me?"
"What kind of medical tests will I have to undergo now that I'm being examined for A-Fib?"
"I was hospitalized with A-Fib. My heart beat was very irregular, but it never went above 100 (my normal resting heart beat ranges from 46-54 because I exercise a lot). Is this different physiologically from what most people seem to have? Should the treatment or prevention be any different?"
"How does age affect A-Fib? I've heard that you can't get an A-Fib ablation if you're too old."
"I'm scheduled to have Mini-Maze surgery. During the operation they cut out the Left Atrial Appendage (LAA) to prevent clots and stroke. But a friend of mine had his LAA closed off, and now he can't exercise like he used to. Does closing off the LAA hurt the heart?"

The following questions deal with medications for A-Fib.
"Which medications are best to control my Atrial Fibrillation?" "I have a heart condition. What medications work best for me?"
"Is the "Pill-In-The-Pocket" treatment a cure for A-Fib? When should it be used?"
"I take atenolol, a beta-blocker. Will it stop my A-Fib."
"I've been on amiodarone for over a year. It works for me and keeps me out of A-Fib. But I'm worried about the toxic side effects. What should I do?"

Warfarin (Coumadin)
The FDA October 19, 2010 approved a new blood thinner med dabigatran which will probably replace warfarin (Coumadin). See Dabigatran to Replace Warfarin.
"Should anyone who has A-Fib be on the blood thinner warfarin (Coumadin)?"
"Which is the better anticoagulant to prevent stroke---warfarin (Coumadin) or aspirin? What's the difference between warfarin and Coumadin?"
"I'm on warfarin. Can I also take aspirin, since it works differently than warfarin? Wouldn't that give me more protection from an A-Fib (ischemic) stroke?"
"What are my chances of getting an A-Fib stroke?"
"I'm worried about having to take the blood thinner warfarin (brand name Coumadin). If I cut myself, do i risk bleeding to death?"
"I am on Coumadin (warfarin) to thin my blood and prevent A-Fib blood clots. Do I now need to avoid foods with Vitamin K which would interfere with the blood thinning effects of Coumadin?"
"The A-Fib.com web site claims that an A-Fib stroke is often worse than other causes of stroke. Why is that? If a clot causes a stroke, what difference does it make if it comes from A-Fib or other causes? Isn't the damage the same?"
"I just had an Electro-Cardioversion. My doctor wants me to stay on Coumadin for at least one month. Why is that required?
They mentioned something about a "stunned atrium." What is that?"
"I know I'm at risk of an A-Fib stroke, but I hate taking Coumadin. Aren't there any natural remedies or supplements I could take?"
"I'm a professional athlete. Someone suggested I get a Watchman device installed or go through surgery to close off my Left Atrial Appendage (LAA), so that I don't have to take Coumadin or other blood thinners. But will closing off or removing the LAA affect my athletic performance, how well my heart pumps?"

The following questions deal with Pulmonary vein ablation (isolation) procedures.
"I'm getting by with my Atrial Fibrillation. I've heard there are a lot of new innovations being developed to treat A-Fib. What are they? Should I wait on having a Pulmonary Vein Ablation till they are developed?"
"Are there different types of "Pulmonary Vein Ablation (PVA)?" Are they different than "Pulmonary Vein Isolation (PVI)?"
"I've heard of ablation catheters that use Cryo (freezing). Are they any good or better than the RF (Radio Frequency) catheters in use today for PVA(I) ablations? What about other energy sources like Microwave, Laser, High Intensity Focused Ultrasound (HIFU)?"
"How dangerous is a Pulmonary Vein Ablation? What are my risks?"
"What is Atrial-Esophageal Fistula? I heard it can kill you. How can it be prevented during an ablation?"
"During the ablation procedure A-Fib doctors actually burn within the heart with RF energy. How does this burning and scarring affect how the heart functions? Should athletes, for example, be concerned that their heart won't function as well after an ablation?"
"I know I need a Pulmonary Vein Ablation (Isolation) procedure to stop my A-Fib. A-Fib destroys my life. I can't work or exercise, and live in fear of the next attack. And antiarrhythmic meds cause me bad side effects.
But I'm worried about being exposed to radiation during the ablation. How dangerous is the radiation (fluoroscopy) during an ablation?"
"I have serious heart problems and chronic heart disease along with Atrial Fibrillation. Would a Pulmonary Vein Ablation help me? Should I get one?"
"I have an enlarged heart due to years of A-Fib. I was told I can't have a Pulmonary Vein Ablation (Isolation) procedure. Why is that?"
"I am 82 years old. Am I too old to have a successful Pulmonary Vein Ablation? What doctors or medical centers perform PVAs on patients my age?"
"I had a successful Pulmonary Vein Ablation (Isolation) procedure a year ago. I'm in normal sinus rhythm and have been A-Fib symptom free. Will my A-Fib eventually return over time, or am I permanently cured?"
"I just had a Pulmonary Vein Ablation (Isolation) procedure, but I still don't feel quite right? How long does it take before I know the procedure was a success?
Also, I've got bruising on my leg, my chest hurts, and I have a fever at night. Is this normal?"
"Where can I get more information on what was done to my heart during my Pulmonary Vein Ablation?"
"Do I have a legal right to obtain my own medical records? Do they belong to me?"
"I've had a successful Pulmonary Vein Ablation to cure my A-Fib. Do I still need to be on anticoagulants like Coumadin or aspirin?"
"Which is preferred to prevent the possibility of a stroke in the event my A-Fib re-occurs---a baby aspirin dosage of 81 mg or a 325 mg?"
"I just had a Pulmonary Vein Ablation. But my A-Fib feels worse and is more frequent than before the ablation. I feel terrible, but I do seem to be getting better each week. Is my ablation a failure?"
"I am having a Pulmonary Vein Ablation next week for my A-Fib. Because i love to exercise, I am very curious as to what and how much physical activity I can participate in after the procedure. Everything i read says 'You can resume normal activity in a few days.' But i know that what is normal is not normal for me. Is there a range of BPM (beats per minute) to keep my heart within? Light walking? Exercising/light weights in the gym? Is there a common road to recovery for those of us who are very physically active?" (Thanks to Monique Van Zeebroeck for this question.)
"I know I'm overweight. Doctors list me as "morbidly obese." But my heart starts racing whenever i try to exercise, because of my A-Fib. What can i do? Should I get a Pulmonary Vein Ablation?"
"I've been in A-Fib for a number of years. I know A-Fib tends to remodel the heart. My left atrium is enlarged and i probably have developed a lot of fibrosis. But I've just had a successful A-Fib ablation and feel great. Will my left atrium, ejection fraction, fibrosis, etc. improve?" (Thanks to Mark for this question.)
" I’ve had two catheter ablations. But they were failures. I don’t feel much better than I did before the ablations. Should I get a third ablation or go for surgery? How many ablations/surgeries are too many?"

Chronic (Persistent) A-Fib
"I have Persistent (Chronic) Atrial Fibrillation (the heart remains in A-Fib all the time). Am I a good candidate for a Pulmonary Vein Ablation? Will it cure me? What are my chances of being cured compared to someone with Paroxysmal (occasional) A-Fib?"
What causes Paroxysmal (occasional) A-Fib to turn into Persistent (Chronic) A-Fib?
"I'm eighty years old and have been in Chronic A-Fib for 2 years. I actually feel somewhat better now than when I had occasional (Paroxysmal) A-Fib. Is it worth trying to get an ablation to cure my Chronic A-Fib?"
"I am in Chronic (all-the-time) A-Fib. I feel tired and a little light-headed, probably because my atria aren't pumping properly. Is there any way I can improve my circulation, without having to undergo a Catheter Ablation (poor success rate and risky at my age) or Surgery (even more risky)?"

The following questions deal with the shock of having an A-Fib attack or diagnosis for the first time.

1. "Around 11:00 pm I was getting ready to go to sleep when my heart started going crazy, like it was trying to jump out of my chest. I panicked and drove to an Emergency room. But by the time I got there, my heart was normal again. What happened to me? My doctor says I may have had an episode of Atrial Fibrillation. How much trouble am I in?"
    It sounds like you may have had an Atrial Fibrillation (A-Fib) attack. A-Fib is probably the most frightening of heart problems. We take our heart for granted until it starts beating wildly out of control. Unlike other heart problems which often build up over time, A-Fib can come on like a ton of bricks, seemingly out of nowhere.
    What happens in A-Fib is the upper parts of your heart (the atria) start beating on their own out of sync with the rest of your heart. It feels like you have mice in your heart or that your heart is flip-flopping around. Your doctor can monitor you to determine if you do have A-Fib.
    A-Fib is a real shock not only to the body but to our minds. Most people who’ve had A-Fib have all-too-vivid memories of their first attack. But as bad as A-Fib feels, it is probably the least immediately threatening heart problem. All things considered, you’re not likely to die from an A-Fib attack. The biggest danger of A-Fib is the increased risk of stroke, because your heart isn’t pumping out properly. But that risk of stroke can be lowered by medications or by the Watchman device.
    A-Fib over time can lead to more serious heart problems (the heart is stretched and weakened). Also, A-Fib may lead to mental deterioration, because the heart isn't pumping properly to the brain (see A-FIB DECREASES MENTAL ABILITIES.)
    As troubling as A-Fib is, many people have learned to live with it all their lives. If that isn’t an option you want to consider, antiarrhythmic medications have helped some people control their A-Fib. Another option is a low risk procedure with a high rate of success called Pulmonary Vein Ablation (Isolation). Another option is surgery to stop the A-Fib.
    The bottom line for you is A-Fib can be cured and/or controlled. There is light at the end of the A-Fib tunnel. (The author was cured by a Pulmonary Vein Ablation procedure in 1998.)

    2. "Did I cause my Atrial Fibrillation? Am I responsible for getting A-Fib?"
    Most likely not. We all remember our first attack of A-Fib---the shock, fear, confusion, the sense of something wrong in our body that we can't control, the rushing to a doctor and/or emergency room. Often there's a tendency to blame ourselves, to feel guilt. We ask ourselves "What did I do or not do that caused my A-Fib?"
    But in general we are not responsible for and didn't cause our A-Fib. Whether we call A-Fib a defect of the heart or body or electrical system or nervous system or an abnormality or predisposition or weakness or tendency or whatever, A-Fib is usually not something we cause or bring on ourselves. It's different than a condition like high blood pressure.
    Especially people with new A-Fib need to think of A-Fib as an act of God or fate or karma or a life accident rather than as something we bring on ourselves. In life sometimes bad things happen to good people through no fault of their own. Think of A-Fib that way. We need to keep saying to ourselves, "I am not responsible for my A-Fib. I did not cause my A-Fib," like a chant or mantra whenever we start feeling guilt or blame for our A-Fib.

    (There are factors somewhat under our control which my influence or trigger A-Fib, such as hypertension, diabetes, obesity and smoking. One study says that half of all cases of A-Fib are due to the above cardiovascular risk factors, with hypertension the strongest predictor of A-Fib.²⁵³(One wonders why the study didn't also mention binge drinking as a cause or trigger of A-Fib. That's certainly something we have control over.)
    Maintaining a healthy diet and life style may help prevent A-Fib. But don't count on them to make you A-Fib free once you develop A-Fib. However, anything that makes you more healthy overall might influence the amount and severity of A-Fib attacks.)

    3. "What caused my A-Fib?"
    That's really hard to say even knowing your life history. Read the section on Causes and see if you think anything applies to you. Many A-Fib cases seem to have no apparent cause or trigger that can be identified with today's medical knowledge.

    4. "Is Atrial Fibrillation a prelude to a heart attack?"
    In general, no. A heart attack is a physical problem with your heart muscles or heart functions. For example, a blocked artery may result in what is called a "myocardial infarction" in which part of the heart tissue actually dies due to a lack of blood. Whereas A-Fib is primarily an electrical or rhythm problem, though it may be related to other heart problems like hypertension and Mitral Valve disease. See Overview.
    However, A-Fib untreated over a long period of time could eventually stretch and weaken your heart, and possibly lead to heart malfunction and a heart attack.

    5. "Can I die from my Atrial Fibrillation?"
    Most episodes of A-Fib are not life threatening. Even though you may feel awful, it's not like having a heart attack.
    The biggest danger from A-Fib is the risk of stroke. Because your heart isn't pumping out properly, blood clots can form and travel to the brain causing stroke. If you have A-Fib, you are five times more likely to have a stroke than the general population. It's most important to take a blood thinner like warfarin (Coumadin) or aspirin to help prevent these clots from forming.
    If you've had A-Fib for a long time, your heart muscles may eventually weaken. You may become more prone to other heart problems. People with A-Fib have nearly double the risk of death compared to someone in normal heart rhythm. ⁶¹See Overview. Also, A-Fib may lead to mental deterioration (see A-FIB DECREASES MENTAL ABILITIES.)

    6. "My doctor says I have Atrial Fibrillation. Could it be something else? Should I get a second opinion?"
    A-Fib is fairly easy to diagnose using EKG's, Holter monitors, etc. If you have A-Fib symptoms and your Cardiologist says you have A-Fib, you probably have A-Fib. Where you may want a second opinion is how to be cured of your A-Fib. See Overview and Cures.
    (But be advised that some milder arrhythmias such as "ectopic atrial tachycardia" and multi-focal atrial tachycardia" can look like A-Fib, but they may need to be fixed by an ablation as with A-Fib.)

    7. "Will my A-Fib go away on its own?"
    On occasion this does happen. In a process called "spontaneous remission" the body adjusts to whatever caused the A-Fib and starts beating normally without any treatment at all. But don't count on this happening. You still need to be under a Doctor's monitoring and care.

The following questions deal with coping with A-Fib.

    8. "What can I do for my husband (wife) when he (she) has an Atrial Fibrillation episode?"
    If your husband/wife is in great discomfort and his/her heart is beating very rapidly and irregularly, you can call 911 or get him/her to an Emergency Room where the staff can use a defibrillator and medications to electrically shock him/her back into normal sinus rhythm, or convert him/her back to sinus rhythm using drugs. But, unlike a heart attack, most episodes of A-Fib are usually not life threatening. See Overview.

    9. "My husband's A-Fib is getting worse. When should I call Emergency and/or take him to the hospital? I'm petrified with fear for him. Our doctors say don't worry unless he shows signs of a heart attack or stroke."
    This is a hard question to answer, because hospitals are limited in what they can do for your husband on an emergency basis. The two main options a hospital has on an emergency basis are:
    1) Electrocardioversion, which is basically shocking the heart to return it to normal sinus rhythm. This doesn't always work, and often the A-Fib returns. Even though your husband will be given anesthesia, the shock may be somewhat traumatic. The electrode paddles may leave burn marks on his chest. If your husband has frequent A-Fib attacks, the hospital can't do Electrocardioversions each time.
    2) Drug cardioversion. Your husband will be given a drug like Cardizem or an antiarrhythmic drug, often intravenously, to return him to normal sinus rhythm. The hospital may have to monitor your husband for three or four days to watch for bad side effects from the antiarrhythmic drug. This drug therapy also doesn't always work, and can't be done every time he has a frequent A-Fib attack.
    For your own peace of mind you need to work out with your doctors a plan, what to do when your husband has an A-Fib attack. It may be to do nothing, unless there are signs of a stroke or heart attack. But you need a plan, specific steps that you both should take. If you aren't satisfied with what your doctor is saying or if you feel he/she isn't addressing your anxieties, get a second opinion.
    Do you think your husband (and you) can learn to live with his A-Fib attacks? Many people live all their lives with A-Fib.
    You both need to realize that people usually don't die from an A-Fib attack, especially if they are on blood thinners like warfarin. As bad as it feels, an A-Fib attack usually isn't life threatening. When an A-Fib attack hits your husband, you can help by getting him to sit down and relax as much as possible. Maybe he needs to be reassured that this isn't life threatening. If you both know from experience that this A-Fib attack will pass, that helps to keep you both calm and get you through it. (I know how hard it is to "relax" when your heart feels like its going to jump out of your chest and is totally out of control.)

    10. "Can I exercise if I have Atrial Fibrillation? Should I exercise? Should I cool my sex life?"
    It's really a judgment call for you and your doctor whether or not you should exercise. In A-Fib when you first start exercising, your heart rate tends to be very rapid. Also, the A-Fib reduces your overall capacity to exercise, because your heart isn't pumping properly.²⁵
    These observations aside, if you can exercise without your heart rate becoming too rapid and you feel like exercising, you probably should. (In some types of A-Fib, moderate exercise may actually help you come out of an attack of A-Fib.)
    If you want to monitor your heart rate while you exercise, you can wear a heart rate monitor (such as the Polar Heart Rate Monitor available in sporting goods stores. Nike and Garmin also make heart rate monitors). It straps around your chest and transmits your heart rate to a watch you wear. You can set it to sound an alarm if your pulse exceeds a certain rate.
    You don't have to worry about dying while making love. Episodes of A-Fib are normally not life threatening.
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    11. "I have a lot of stress at work. Does this stress cause or trigger my A-Fib?"
    There's always going to be some stress in life. Nobody lives a stress-free life. It's part of the human condition.
    Remember that A-Fib, unlike other heart problems, is primarily a physical problem, a defect in your heart. If you have something like high blood pressure, stress may harm you. But it isn't all that big a factor in A-Fib. You could be lounging on a swing on a tropical isle and still have A-Fib attacks.
    However, there are life events like the sudden death of a family member or friend, which can't help but affect us in every part of our body and mind. These life-changing crises can certainly produce stress which might cause or trigger A-Fib.

    12. "Can I drive my car if I have Atrial Fibrillation?"
    In general, yes. With most types of A-Fib you can drive safely. But if your episodes of A-Fib cause dizziness, you need to determine if you can safely drive. If your A-Fib episodes cause you to become dizzy, as soon as you feel the beginning of an episode of A-Fib, pull off to the side of the road and stop. Wait there until the episode passes. If this happens often or if your episodes of A-Fib last a long time, you may have to stop driving entirely.
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    13. "How can I tell when I'm in A-Fib or just having something like indigestion?"
    Without medical help you may not be able to tell if you have A-Fib or something like indigestion. Many people have "silent A-Fib" which is A-Fib with few or no symptoms. "Silent A-Fib" can be very dangerous. It can lead to stroke, circulation problems, heart problems, mental deterioration. Some doctors advocate mandatory A-Fib screening for anyone over 60. (See "Silent A-Fib"). (It's been reported that indigestion is sometimes a side effect of an A-Fib attack.)
    To verify if you have A-Fib, a doctor can give you an ECG test or can have you wear during the day a monitoring system such as a Holter monitor. Only a doctor can determine if you have A-Fib.
    If you want to monitor yourself (which may not necessarily be a good idea), you can take your own pulse or use an over-the-counter heart monitoring device such as the Polar Heart Rate Monitor used by runners. It's worn around your chest and transmits a signal to a wristwatch that beeps when your pulse goes too high. You can check the digital display on the watch to see how fast your pulse is. (When I had A-Fib, I used the Polar monitor whenever I tried to jog. In fact I eventually wore it all the time, which was probably a bit obsessive. But it did alert me to "silent" A-Fib attacks I normally wouldn't have been aware of.)
    Warning: any over-the-counter device is no substitute for monitoring and treatment by a doctor. You should not use over-the-counter devices to diagnose yourself.

    14. "Is there anything I can do to get out of an A-Fib episode? Is there any way to predict when I'm going to have an A-Fib attack?"
    The "pill-in-the-pocket" approach is reported to be often effective in stopping an A-Fib episode. Under a doctor's direction, you take the antiarrhythmic meds flecainide (brand name Tambocor) or propafenone (Rythmol) whenever you feel the start of an attack of A-Fib. The dosage is determined by your doctor.
    (Most of the following is anecdotal, what people have reported, rather than based on scientific studies. Please use discretion in trying any of the following.)
    - Magnesium and/or Potassium supplements have been reported to help A-Fib attacks. Some people soak in Epsom salts for twenty minutes to get out of an A-Fib episode. See Natural Remedies and Epson Salts Cure. [Ian in Australia recommends a Martin and Pleasance product called "Magnesium Phosphate Spray" (available only in Australia/New Zealand) and Magnesium Orotate.]
    - Mild exercise has been reported to be helpful in getting out of an A-Fib episode, but in other cases exercise may trigger A-Fib.
    - Resting and lying down in a darkened room during an A-Fib episode.
One person suggests, "...lying down on my bed without a pillow, relaxing my body and mind, and keeping my body very warm."
    - The application of cold compresses or ice packs to the back of the neck.
    - Putting one's head between one's knees and/or breathing down hard on one's diaphragm.
    - Taking a hot bath or shower (which seems to contradict the use of cold packs above).
    (If you have any remedies which have worked for you to bring you out of an A-Fib attack, please let me know at Feedback. I'll include them here.)
    Predicting an A-Fib episode. You may want to try keeping a log or diary of your A-Fib episodes for three or six months. By checking this log you may find, for example, that your A-Fib episodes come mostly at night or after a meal, which may mean you have Vagal A-Fib. What is the interval between your A-Fib episodes? Some people have very regular intervals between A-Fib attacks.
    Do you feel Premature Atrial Contractions (PACs) before an A-Fib attack (they feel like extra atrial beats)? PACs often occur prior to an A-Fib episode. If so, you may want to talk with your doctor about getting a prescription for an antiarrhythmic drug you can take when you get these PACs (called a “Pill-In-The-Pocket” treatment.) They may stop or shorten an A-Fib attack.

    But in general A-Fib seems to have a mind and schedule of its own that's often hard to predict. (When this author had A-Fib, he had very short episodes no longer than five minutes, but often during the day. He was never able to predict when they would occur, or identify what may have triggered them.)

    15. "I have A-Fib. In case of an emergency, should I carry a wallet card or a medical bracelet? What information should I put on it?" (Thanks to Darrel Seife for this question.)
    According to a Paramedic with 25 years experience, knowing about your A-Fib and Coumadin use is "nice-to-know" rather than life-saving, necessary info. Emergency responders don't normally carry meds to treat A-Fib. In case of an accident when one is bleeding, techniques to stop the bleeding such as compresses, tourniquets, etc. will be used whether or not one is taking Coumadin.
    Whether or not one has A-Fib, it's generally a good idea to have medical ID in case of an emergency. A medical bracelet or dog tags are more often noticed by emergency personnel than wallet cards. To obtain a free wallet medical ID card, you can go to the following site: http://www.medids.com/free-id.php. (The author is not recommending the products on this site, but only listing it as a convenience for visitors to A-Fib.com.)

    16. "Is drinking coffee (tea, colas, other products with caffeine) going to make my A-Fib worse or trigger an A-Fib attack?"
    The author used to include coffee as a trigger of A-Fib, but recent research suggests that coffee and caffeine in moderate to heavy doses (2-3 cups to 10 cups/day) may not trigger or induce A-Fib.^144,
145 Coffee (caffeine) may indeed be antiarrhythmic and may reduce the propensity and inducibility of A-Fib both in normal hearts and in those with focal forms of A-Fib.¹⁴³(Thanks to contributor Karl for calling our attention to these articles.)
    The researchers who discovered the antiarrhythmic effects of coffee (caffeine) were somewhat surprised at their findings. They had expected to find the opposite results. Caffeine is a stimulant. It makes its consumers awake and alert, and it improves performance.¹⁴⁷
    Coffee (caffeine) is commonly associated with disruption of cardiac rhythm. But does research confirm this belief? "Most cardiac patients tolerate normal amounts of caffeine without difficulty."¹⁴⁸ Frost and Vestergaard, in a study of 50,000 middle-aged people followed for around six years (the Danish Diet, Cancer, and Health Study, 2005), found that caffeine does not increase the risk for developing A-Fib. The daily consumption of caffeine from coffee, tea, cola, cocoa, and chocolate was quite high, as is usual in Scandinavia where people drink 2-3 cups to 10 cups of coffee per day.¹⁴⁵
    But researchers are currently unable to identify the mechanism(s) behind coffee's potential antiarrhythmic effect. Researchers hypothesized that caffeine may protect from A-Fib by inhibiting adenosine A1 and A2 receptors. "Selective blockade of the adenosine A1 receptor was shown to result in a decrease in AF propensity."¹⁴³
    The important research question is, how does coffee (caffeine) affect you personally? If you drink a cup of coffee and then have an A-Fib attack, you may have to stop drinking coffee. But for others, a blanket prohibition against drinking coffee probably isn't justified by current research. In fact, coffee (caffeine) may have antiarrhythmic effects.
    Contributor Allan, cured of Persistent A-Fib after two ablations at Bordeaux, writes, "I tried many different things both mainstream and alternative to get relief from A-Fib. I also observed and noted triggers with a great deal of intensity, so I feel compelled to comment on the latest post regarding the positive effects of Coffee/Caffeine. I never had anything other than bad effects from coffee on my A-Fib. Coffee/caffeine was a significant trigger for me...even in very small doses. So I guess my story underscores the complexity of triggers/suppressants across the general population.
    I do hope people reading that report don’t go out and dose up on coffee. We all know that coffee will make our hearts go faster, which is probably not good."

    17. "Is smoking medically prescribed marijuana or using Marinol going to trigger or cause A-Fib? (Marinol is a pill prescription form of marijuana, also known by the generic name dronabinol.)
    There isn't much clinical research on this subject. However, the makers of Marinol advise that it “should be used with caution in patients with cardiac disorders (like A-Fib) because of occasional hypotension, possible hypertension, syncope, or tachycardia. Dronabinol-induced sympathomimetic activity may result in tachycardia.”
    In a search of the published medical literature, the makers of Marinol found no studies evaluating the use of Marinol in treating A-Fib. They have no plans to conduct any such studies.
    The bottom line is marijuana or Marinol is more likely to trigger A-Fib or tachycardia than not. But we all react differently to meds.

    18. "Can excess iron in the blood (Iron Overload Deficiency, Hemochromatosis) cause Atrial Fibrillation? How do I know if I have IOD? What can I do about it?"
    Not only does excess iron in the blood trigger or predispose you to A-Fib,²⁸⁴ it injures and eventually can kill a variety of body organs like the liver and gall bladder. "Undiagnosed, untreated iron overload, regardless of its origin can lead to diabetes, arthritis, depression, impotence, liver-gall bladder disease, complete liver failure, heart attack, cancer."⁴⁹ (chronic fatigue and Alzheimer’s). "...excess iron is toxic and can injure every part of the body, including the brain."⁵⁰ And IOD is a much more widespread condition than people are aware of. Genetic IOD (Hereditary Hemochromatosis) is the most common genetic disorder among Caucasians in the U.S.⁵⁰ One can also develop excess iron by absorbing too much from supplements, iron-rich diet, tobacco and other sources.
    When you have your annual physical exam, your doctor should check for iron overload. The most common tests are:
        1. Transferrin saturation (TS), also called "Percentage of Saturation." After fasting, blood is taken to measure Total Iron Binding Capacity (TIBC) and Serum Iron (SI). SI is divided by TIBC to get the Percentage of Saturation. A safe range is 12-44%. Over that is considered iron overload.
    2. Serum ferritin concentration (stored iron). A safe range is 5-150. (If the first TS test comes out OK, this test may not be done.)⁵¹
    3. Hemoglobin. Iron is used by the body for hemoglobin production. Hemoglobin is the iron-containing respiratory pigment in red blood cells. The top normal level is 14 for women, 15 for men.
    4. Hematocrit. The percentage by volume of packed red blood cells in a given sample of blood after centrifugation (i.e., the percentage of red blood cells in your blood). The top normal level is 42 for women, 45 for men.
    5. Another test given less frequently is the UIBC which measures Unbound Iron Binding Capacity. A safe range is above 146. If you’re below that, you should be treated for iron overload.
    If you have iron overload (IOD), you and your doctor must act aggressively to get rid of that excess iron as fast as possible. It won’t go away by itself. "Unfortunately, the body has no way to rid itself of excess iron."⁵² To get your iron levels down, you have to give blood through a "phlebotomy" program at your doctor’s office or blood bank as often as once or twice a week. Drugs known as chelators can also remove excess iron from the blood.
    To prevent iron overload (IOD), many of us, particularly men, would benefit from donating blood on a regular basis. Pre-menopausal women normally loose blood monthly thereby lowering their iron levels, but in men the iron just accumulates with age. "When you donate blood, the life you save may be your own." (Thanks to Isabelle Horowitz for much of this info on IOD.)
    For more info on hemochromatosis see http://www.ironoverload.org

    19. "Can too little iron in the blood (Anemia) cause Atrial Fibrillation? What can I do about it?"
    (Thanks to Sally Mertens for this response. "Based on my experience dealing with chronic A Fib, I would stress the importance of having ferritin level checked. Once a doctor (my GYN [Gynecologist] not my Cardiologist!) figured out that my chronic A-Fib might be related to my low ferritin level (9), after only 6 weeks of taking Repliva (82 mg/day iron), my ferritin was up to 29 and my A Fib had stopped. (Another over-the-counter iron supplement is Floradix.) I haven’t had one A Fib attack since I started the Repliva.
    I concurrently stopped donating blood (which I was doing as frequently as possible) and began eating beef - at least 8 ounces per week - (after 3 years as a vegetarian).
    My GYN would like to see my ferritin level at about 50 and told me it would take about 6 months for me to get my blood “stores” back to normal. I feel extremely lucky and grateful that when I moved to a new town, I got referred to a GYN who was well aware of the link between anemia in pregnancy and heart conditions. (As a footnote, every time I donated blood, I passed the Red Cross hemoglobin test. My GYN understood how that was possible, but I didn’t understand the explanation well enough to share it with you here.)
    I’m well past child-bearing age and thus, as a precaution, my GYN also sent me for a colonoscopy to rule out internal bleeding as a factor in my low ferritin.

General A-Fib Questions

    20. "Why does so much Atrial Fibrillation come from the Pulmonary Vein openings?"
    Perhaps because the embryonic origin of the Pulmonary Vein openings (Ostia) is the same as that of the Sinus and AV Nodes. They are similar in structure and have similar smooth muscle tissue. The Pulmonary Vein openings are electrically active in the heart like the Sinus and AV Nodes but usually beat in sync with them. Disease, viral infections, stretching, fibrosis, or other factors may cause the Pulmonary Vein openings to start beating out of sync with the Sinus and AV Nodes thereby producing A-Fib signals. (Please be advised that the above statement is an observation, an attempt to explain, rather than a medical fact. Further research is necessary to confirm this observation.)

    21. "Is my Atrial Fibrillation genetic? Will my children get A-Fib too?"
    Some research has identified a Familial A-Fib where A-Fib is passed on genetically,²⁸ but it is relatively rare. Even though the gene responsible for inherited A-Fib has been identified,⁴⁶ there hasn't been enough research on the genetics of A-Fib to say whether or not your children will inherit your A-Fib. However, there are many causes or triggers of A-Fib that are not genetic. Your A-Fib may not be genetic, in which case you won't pass it on to your children. (See Causes.) (Also see the studies of Dr. Ellinor.)
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    22. "Why do older people get Atrial Fibrillation more than younger people?"
    This may be related to what is called "Interstitial Fibrosis" which is often part of the aging process. The Pulmonary Vein openings (where most A-Fib signals originate) sometimes become fibrous as we age. The Pulmonary Vein openings are similar in structure and have similar smooth muscle tissue as the Sinus and AV Nodes which generate your normal heart beat signal. The Pulmonary Vein openings are electrically active in the heart like the Sinus and AV Nodes but usually beat in sync with them. When the Pulmonary Vein openings become fibrous, they tend to beat out of sync with the Sinus and AV Nodes which results in A-Fib. (Please be advised that the above statement is an observation, an attempt to explain, rather than a medical fact. Further research is necessary to confirm this observation.)

    23. "Is Atrial Fibrillation (A-Fib) different from what doctors call Paroxysmal Supraventricular Tachycardia?" (Thanks to Sol Yuyitung for this question.)
    "Supraventricular" refers to the upper part of the heart, the atria. "Tachycardia" means the upper part of your heart is beating faster than normal. "Paroxysmal" means occasional.
    "Supraventricular Tachycardia" in clinical practice commonly refers to atrial tachycardia, atrioventricular nodal reentrant tachycardia (AVNRT), and atrioventricular reciprocating tachycardia (AVRT), an entity that includes Wolff-Parkinson-White syndrome. While Atrial Fibrillation is a distinct entity classified separately.
    The term "Supraventricular Arrhythmia" most often is used to refer to Supraventricular Tachycardias and Atrial Flutter.
    In practice, "Supraventricular Tachycardia" is often used loosely to include all arrhythmias in the Atria, including A-Fib.

    24. "What is the difference between "Adrenergic" and "Vagal" Atrial Fibrillation. How can I tell which one I have? Does it really matter? Does Pulmonary Vein Ablation (Isolation) work for Adrenergic and/or Vagal A-Fib?"
    To the list of the causes or triggers of A-Fib such as heart disease, thyroid problems, fibrosis, etc. (See Causes), we should also add the malfunctioning of the Sympathetic and the Parasympathetic Nervous Systems.
    The Sympathetic Nervous System reacts to stress, stimulants, etc. causing the heart to speed up and the blood vessels to constrict. A-Fib arising from an overactive Sympathetic Nervous System is called Adrenergic A-Fib (adrenaline stimulates the heart to beat faster and stronger when the body demands more oxygen).
    The Vagus Nerve, in contrast, controls the abdomen and is part of the Parasympathetic Nervous System which slows the heart and dilates the blood vessels. A-Fib arising from an overactive Parasympathetic Nervous System is called Vagal (Vagotonic) A-Fib.
    Adrenergic and Vagotonic forms of paroxysmal A-Fib are uncommon.⁴³ "The majority of patients with paroxysmal A-Fib do not have a clear autonomic pattern."¹¹⁰ However, if your A-Fib occurs usually during the day and is normally triggered by exercise, stress, stimulants, exertion, etc., then you may have "Adrenergically-Mediated" A-Fib. People with structural heart disease seem more prone to Adrenergic A-Fib⁴⁴. But if your A-Fib occurs at night, after a meal, when resting after exercising, or when you have digestive problems, then you may have "Vagally-Mediated" A-Fib. People with Lone A-Fib seem more prone to Vagal A-Fib⁴⁴. (Many people have a mix of both Adrenergic and Vagal A-Fib.) (Perhaps A-Fib begins as a nervous system problem, then becomes a heart problem after the arrhythmia is established.)
    It might be helpful to determine if you have one or the other so that you can better identify what triggers your A-Fib, and because the treatments are often different for each. For example, beta-blockers usually don't work well with Vagal A-Fib.⁸⁶ (One person with Vagal A-Fib E-mailed that his A-Fib was caused or triggered by a beta-blocker.)
     Of the antiarrhythmic 1c meds, flecainide seems to work better for Vagal A-Fib than propafenone.¹¹¹ (Though it's difficult to generalize about A-Fib treatments, because each person reacts so individually.) For a more in depth look at Vagal A-Fib, go to Vagal A-Fib (But please be advised that this info is taken from an old web site that is no longer maintained. Many of its links no longer work. [Thanks to Yvonne Woudenberg for pointing out this problem.] We are working to develop more up-to-date info on Vagal A-Fib.)
    Current research hasn't indicated yet whether Pulmonary Vein Ablation is more or less effective or appropriate for Adrenergic than for Vagal A-Fib. However, it seems that both Adrenergic and Vagal A-Fib are focal in origin (come from specific points or spots in the heart), and can presumably be cured by current Pulmonary Vein Ablation (Isolation) procedures.

    25. "I had a single episode of A-Fib 17 months ago and was successfully converted with medication (Cardizem drip). That day I had only four hours of sleep, had eaten no breakfast, but did have an extra large coffee. I also had watery diarrhea and was somewhat dehydrated. Is it possible that my electrolytes were out of whack and led to the A-Fib episode? Other than an occasional PAC of PVC, I haven't felt any A-Fib symptoms since. I'm wondering if it's possible to have a single A-Fib attack and not have any others." (Thanks to Joan for this question.)
    Once an area or areas in your heart start producing A-Fib pulses, it's usually hard to turn them off again. But whatever you did seems to have worked for you.
    Have your doctor keep track of your blood chemistry to make sure you don't get into chemical imbalances that might trigger A-Fib again. (When you went to the hospital for that single episode of A-Fib, what kind of imbalances did they find?) You may want to look into taking supplements or foods that help keep your heart chemistry in balance. (See Natural Remedies.)
    PACs and PVCs are considered benign---people with normal hearts have them. But in A-Fib they often seem to be precursors of an A-Fib attack.
    For your own peace of mind, ask your doctor for a Holter or other type of monitor which you would wear for one or three days. This would tell if you have any "silent" A-Fib which you may not be aware of, but which can be dangerous.

    26. "I've had A-fib for several years and have read that it may produce fibrosis and collagen deposits in the atrium (See: A-Fib Induces Fibrosis). How can I determine or measure how much fibrosis I have? Can something non-invasive like a CT scan measure fibrosis?" (Thanks to Stewart Stafford for this question.)
    To the best of my current knowledge, a CT scan does not measure Fibrosis. EPs currently can measure fibrosis by going inside the heart and mapping fibrosis with a voltage monitoring catheter.
    Recent research indicates that Fibrosis can be measured by an MRI.^169, ¹⁷⁰

The following questions deal with Treating or Curing A-Fib.

    27. "Is Atrial Fibrillation curable? Or can you only treat or control it?"
    A-Fib is definitely fixable. If you have A-Fib, no matter how long you've had it, your goal should be to be A-Fib free. If your doctor is satisfied with keeping your A-Fib "under control," get a second opinion.
    But, if you are eighty or older, have a severely enlarged atrium (over 55 cm), or have other conditions which might make an A-Fib ablation more risky for you, you need to weigh the risks and probability of success with your doctor.

    28. "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.
    (Not mentioned in these options is the use of "natural remedies" and supplements like Magnesium and Potassium. Read the section on Natural Remedies to see if any of these supplements may help your A-Fib.)

"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 cardioversion, 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.
"I have occasional (Paroxysmal) A-Fib with no 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.)
"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.
    (Editor's Suggestion: If you are on an antiarrhythmic med and are going to have a Pulmonary Vein Ablation (Isolation) procedure, you may want to talk with your doctor about stopping the antiarrhythmic med at least four days before your ablation. Otherwise the antiarrhythmic med may mask A-Fib sources in your heart. [Thanks to Ian Betts for this observation.]
    "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.
    (Editor's Suggestion: If you are on an antiarrhythmic med and are going to have a Pulmonary Vein Ablation (Isolation) procedure, you may want to talk with your doctor about stopping the antiarrhythmic med at least four days before your ablation. Otherwise the antiarrhythmic med may mask A-Fib sources in your heart. [Thanks to Ian Betts for this observation.]
"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).
    If your heart problems require surgery, you may want to consider going to a surgeon who can perform a Maze operation at the same time.
"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 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-Fib, since they currently can't reach or block all areas of the heart where A-Fib signals are found.
"I have Persistent or Chronic (all-the-time) A-Fib but no symptoms ('silent') A-Fib."
    You may want to consider just learning to live with the A-Fib. You will have to be on blood thinners or have a Watchman device installed to keep from having an A-Fib stroke. You will probably have to take rate control meds to keep your heart from beating too fast. Your heart isn't pumping out properly, but you can compensate to some extent by exercise. You may be able to lead a close-to-normal life in silent Chronic A-Fib. It's hard to justify the effort and risk necessary to fix Chronic A-Fib if you have no A-Fib symptoms.
    Chronic A-Fib is harder to fix and often requires at least two ablations. An unintended consequence of a successful ablation for Chronic A-Fib is your A-Fib may be improved so that you are only Paroxysmal (occasional). But Paroxysmal A-Fib may be more debilitating and troublesome than being in Chronic A-Fib. At least in Chronic A-Fib you don't have to worry about an A-Fib attack.
    A Cox Radial Maze to fix Chronic A-Fib is open heart surgery which is very traumatic and risky. It's hard to justify open heart surgery if you're feeling OK.
    Another factor to consider is your age. If you're 40 years old, it's probably worth the effort to get your silent Chronic A-Fib fixed. Chronic A-Fib over time will probably damage your heart, brain, and other organs. But if you're in your 70s, you can probably live the rest of your life in a satisfactory, fulfilling manner even with silent Chronic A-Fib.
    However, having had A-Fib, the author knows how wonderful it is to be in normal sinus rhythm. Even though you have silent Chronic A-Fib and in general feel OK, you may want and need to get rid of your Chronic A-Fib. Most doctors understand this need to have a heart that beats normally and will work with you, as long as you understand the risks and challenges. See the options under I Have Chronic A-Fib.
"I have A-Fib but am allergic to Coumadin, Heparin, Lovenox and most blood thinners. I'm also very overweight. And I've already had one stroke."
    You might be a good candidate for a Mini-Maze operation, since you don't have to be on blood thinners during and after a Mini-Maze operation.
    A Mini-Maze is possibly a better option if you have had a stroke or are more in danger of having a stroke during a catheter ablation.
    The Mini-Maze is sometimes a better choice if you are "morbidly obese." With current fluoroscopic imaging systems used in catheter ablation, it's more difficult to see a clear image of the heart if someone is overweight. And greater doses of radiation often have to be used.²⁰⁷
    The various Mini-Maze surgery devices are not currently approved by the FDA for the treatment of A-Fib. But they can be used "off-label." (The only currently approved FDA devices for the treatment of A-Fib are catheter ablation strategies: The two radiofrequency catheters, the NaviStar ThermoCool and EZ Steer ThermoCool Nav (BioSense Webster); and the cryoablation balloon catheter for A-Fib---the Arctic Front system (Medtronic, Minneapolis, MN).)
PROS AND CONS OF THE MINI MAZE OPERATION
     Though not open heart surgery like the Cox Radial Maze, the Mini Maze operations are nevertheless very traumatic for the body and require general anesthesia. (Think of multiple knives being stuck through your chest.) Your Pericardium is cut or punched open. Your Left Atrial appendage is cut out and/or stapled shut while the heart is still beating which can be technically challenging. Your lungs have to be alternately deflated and inflated which can be very difficult for older people whose lungs aren't very elastic. And "approximately 6% of patients may require a pacemaker."²⁶⁹
    To be effective the ablations have to be transmural; i.e., they have to penetrate all the way from the outside of the heart to the inside. A lot of RF or Microwave energy has to be delivered which often results in fairly extensive scarring of the heart. This extensive scarring may eventually harm the functioning of the heart and is of special concern to young, athletic patients. However, we don't have enough data yet to either confirm or deny this suspicion.
    The biggest drawback to Mini-Maze operations is that they can't currently reach or block all areas of the heart where A-Fib signals may originate. If you have a simple case of recent onset A-Fib that requires only the isolation of the Pulmonary Vein openings, the Mini Maze operation may work for you. But anything more complicated is questionable. Recent data suggests that a Mini-Maze "is applicable to less than 1% of the AF population."²⁷⁰ Currently surgeons don't have the ability to map inside the heart to identify sites where A-Fib originates. For example, patients with long-standing persistent (complicated) A-Fib tend to have relatively poor results. One study cites a 46.2% success rate after three months.²⁴⁶
    One considered advantage of the Mini Maze operations is that the Left Atrial Appendage (LAA) is cut out and/or stapled shut. Most A-Fib blood clots which cause stroke come from the Left Atrial Appendage. By cutting out or closing off the Left Atrial Appendage, most but not all risk of stroke is eliminated even if you are still in A-Fib.
    However, the success rate for closing off the LAA by surgery currently isn't anywhere near 100%. In a study by Dr. Damiano, Jr., "both suture exclusion and stapler exclusion had extraordinarily low success rates. In fact, none of the patients with stapler exclusion had successful closure...This study presents clear evidence of the inadequacy of these techniques."¹⁵⁰ (The Watchman Device (in clinical trials but available for most patients) has a better success rate for closing off the Left Arial Appendage and involves less risk.)
    (You may want to read in the PersonalExperiences section a description of THE SALTMAN MICROWAVE MINI MAZE OPERATION. [as of 2009 the Saltman Microwave Mini Maze operation isn't currently available])
    A Mini-Maze is considered overkill for simple cases of Paroxysmal (occasional) A-Fib. In Surgeon Andy C. Kiser's practice, "When a patient has paroxysmal A-Fib and the left atrium is under 4.5-5.0 cm, we recommend percutaneous catheter ablation. In this population, simple pulmonary vein isolation may be effective in over 80% of patients."²³⁷ Surgeon James Edgerton does not normally operate on Paroxysmal (Occasional) A-Fib patients. "I think they are very well treated with catheter ablation." See Dr. Edgerton's presentation on Hybrid Ablation.
    In general, Mini-Maze surgeries "usually have significant risks compared with catheter-based electrophysiology procedures such as catheter ablation."²⁵⁵
    You may also want to consider the differences in education, training, mind set and attitudes of Surgeons vs. Electrophysiologists. A surgeon's primary concern is in performing a successful operation, whereas an EP has devoted his/her whole life to dealing with heart rhythm problems. Surgeons in general don't often follow patients after surgery to address heart rhythm problems. That isn't usually part of their training.
    In an ideal world a surgeon would work with and consult an EP, especially if the surgery didn't work. But, with certain exceptions, that generally isn't the case today.  (However, see Hybrid Ablation where Surgeons and EPs do work together on the same patient.)
    (The author realizes his opinions on the Mini Maze operations are somewhat controversial and welcomes rebuttals and contrasting opinions which will be published here.)
    The Cox Maze IV might be an option you should consider, though an allergy to blood thinners may influence whether or not the surgeon takes your case and may affect elements of the operation. If your left atrium is larger than 6.0 cm or you've been in A-Fib for over five years, the long term success of the "Cut and Sew" Maze operation is under 80%.²³⁷ See Advances in Surgical Therapy for A-Fib.
"I've had two failed left atrium ablations and have tried many different medications."
    You can go for a third left atrium ablation, but you need to go to the best, most experienced A-Fib doctors you can find. You are a special case and deserve special treatment.
    The Mini Maze operations probably wouldn't work for you because of the reasons mentioned above (see Pros and Cons of the Mini Maze operations.)
    A Cox Radial Maze operation may work for you. (Added 12/20/10: There is a new type of Mini-Maze operation called the "Five-Box Thorascopic Maze Surgery" which was developed by Dr. John Sirak of the Ohio State University. According to Dr. Sirak's web site, it has a "cure rate in excess of 95%." [Author's Note: This Mini-Maze surgery may be an alternative to the full Cox (Radial) Maze surgery for A-Fib.]
http://www.ohioafib.com/maze-surgery/)
    A last option is Ablation or Modification of the Atrioventricular (AV) Node and Implanting a Pacemaker. Though you are still in A-Fib and have to continue taking blood thinners and probably rate control meds, your ventricles are no longer affected by A-Fib. In general people report a better quality of life than when A-Fib made their heart race.

    29. "Is there a diet I could follow which would cure my A-Fib?"
    Current empirical medical research hasn't identified a diet which would cure your A-Fib.
    You may want to lessen or eliminate how much alcohol you drink. Heavy consumption of alcohol may trigger A-Fib. Some cases have been reported where the caffeine in coffee is said to have triggered A-Fib. You may want to try eliminating other stimulants (tea, chocolate, tobacco, MSG, sodas) and see if that helps your condition. Try keeping a diary of what you eat. If you drink coffee for example, try not drinking any for one or two weeks. (Some people claim to have been helped by eliminating all dairy products from their diet.) A recent study from England suggests that eggs and poultry meat may cause or trigger A-Fib.⁶³ See A-FIB NEWS Eggs and Poultry Meat may trigger A-Fib.
    In general a healthy diet would improve your overall health and thereby possibly improve your A-Fib.
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    30. "Are there exercises that will help eliminate my Atrial Fibrillation?"
    No. Our current knowledge of A-Fib hasn't identified any exercises that would help eliminate your A-Fib. (Some people say they can come out of an A-Fib attack by splashing their face or back with ice water or by bearing down hard using their diaphragm. Others report that hard exercise can often get them out of an A-Fib attack.)

    31. "I like my Cardiologist, but he has not talked about me seeing an Electrophysiologist. Should I ask for a second opinion from another Cardiologist?"
    Most definitely. But try to get a second opinion from an Electrophysiologist, rather than a Cardiologist. An Electrophysiologist is a Cardiologist who specializes in heart rhythm problems. In fact, it's easy to find a local Electrophysiologist yourself. The Web site of the Heart Rhythm Society has a feature called Finding A Heart Rhythm Specialist. When you type in your State and City, the site gives you a list of Electrophysiologists in your area.
    However, not all Electrophysiologists perform and have sufficient experience in Pulmonary Vein Ablation (Isolation). Use our Web site's QuestionsForDoctors and Facilities sections to help select the right Electrophysiologist for you.

    32. "I have a lot of extra beats and palpitations (PVCs and/or PACs) which are very disturbing and frightful. They seem to proceed an A-Fib attack. What can or should I do about them?"
    Currently A-Fib doctors aren’t overly concerned about extra beats (Premature Ventricular Contractions---PVCs or Premature Atrial Contractions---PACs), because they are considered 100% benign. Everybody gets them, not just people with A-Fib.
    However, there is anecdotal testimony that extra beats do seem to proceed or forewarn of an A-Fib attack. And A-Fib-ers seem to have more problems with extra beats than normal people. Also, after a successful A-Fib PVA(I) ablation, people seem to have more extra beats which tend to diminish over time as the heart heals and gets used to beating properly. (If the PVCs and PACs do not turn into A-Fib, it may mean that the AV Node/Sinus Node signals are strong enough to override the PVCs and PACs and keep you in NSR.)
    If these extra beats cause you problems, beta blockers and antiarrhythmic meds used to treat A-Fib may help. Some people recommend the Valsalva maneuver---closing one's mouth and pinching one's nose shut while forcing exhalation, or sticking one's head in a sink of really cold water.
    Also, during an A-Fib ablation procedure, sometimes sources of extra beats can be identified and ablated. However, during an ablation doctors will be more concerned with eliminating your A-Fib and A-Flutter than with extra beats.
    (Added January 31, 2011.) Recent medical thinking about A-Fib confirms the importance of extra beats in A-Fib, "These premature beats occur before the atria are expecting it, at a somewhat vulnerable period that may provoke or trigger A-Fib...Elimination of these premature atrial beats with medication or catheter ablation has proven effective as a therapy to potentially "cure" paroxysmal A-Fib." http://www.washingtonhra.com/41.html Dr. Pirooz Mofrad.)

    (The author would like to thank Ian Betts for writing the following observations about ectopic beats.)
    Ectopic heart beats can be likened to a starter motor for the main fibrillation engine - the more the starter motor turns, then the more likely it will fire up the fibrillation. Lone ectopics during the course of a day are generally not so much of a concern. However, when the time period between successive ectopic beats is short or if you start to get strings of ectopic beats, then you are at risk of having an A-Fib episode start.
    It can drive you crazy trying to work out why ectopics (and A-Fib) start up after a period of relative calm. However, if you closely monitor your activities, you may be able to backtrack and pinpoint what is causing the ectopics to become active. The following suggestions (in no particular order) may be helpful:
1. Are you getting enough sleep? If your ectopics are worse toward the end of your working week, then they could be the result of fatigue. Get plenty of sleep at the front end of the working week.
1. Are you properly hydrated? Again if you work or exist in an air conditioned environment, you need to ensure you have adequate fluid intake. Get a standard water jug and aim to drink a full jug in the morning and a full jug in the afternoon.
1. Have you had a blood test? Before diving into taking supplements, it would be better to have a blood test to determine whether your sodium, magnesium, potassium levels, etc. are in the proper ranges. Taking high levels of supplements which are not needed may snowball your problems by putting extra strain on the liver, kidney and other organs - remember A-Fib generally won't kill you but liver failure will. The writer of this piece has tried virtually every suggested supplement and concluded most had a placebo affect at best. That said, some relief may be obtained from a low dose Magnesium Orotate supplement (I take 2 Orotate tablets daily - equivalent to elemental magnesium of 30 mg each).
1. Do you have a parched feeling in your mouth accompanying the ectopics or in the lead up to an A-Fib episode? Again fluid intake should be considered, but supplement the fluid intake with a banana or two until the parched feeling goes away.
1. Do the ectopics happen sitting down? It could be the angle you are sitting at is causing the ectopics, e.g., leaning a little forward at a meeting table or leaning forward working on a computer may cause them.
1. Do the ectopics get worse before meal time? If so, maybe you should be eating more fruit between meals.
1. Do the ectopics get worse after a meal? If so, maybe you have eaten too much and should try eating smaller meals. The ectopics, however, may be caused by food additives in what you are eating. As a general rule go for the food items which have the least amount of processing, like roast potato as opposed to mashed potatoes which may have some extra enhancers mixed into the mash.
1. Do the ectopics get worse after a restaurant meal? If so, you may be affected by flavor enhancers, etc. used by the restaurant. If this is the case, you should consider taking a Nexium tablet (or similar) before eating at a restaurant. Nexium could be used as a pill in the pocket treatment if a meal has upset you. (It may take a day or so for everything to calm down, so you need to be careful to eat plain food during this period).
1. Do the ectopics happen when you are exercising? Consider revision of your exercise routine - maybe you are going too hard.
1. Have you considered the consumption of stimulants? This is pretty self explanatory - caffeine drinks and some chocolate bars can easily trigger ectopics. White wine and to a lesser extent red wine may cause a problem (generally cheap white wine should be avoided).
1. Are ectopics/A-Fib worse at night? Try eating a smaller evening meal and have a banana for desert - bananas are a natural antacid. Also, don't eat your evening meal and then go straight to the TV chair. Stay on your feet for at least half an hour after the meal; even go for a leisurely walk around the block. When you go to sleep, start off sleeping on your back and try not to sleep on your side for at least 3 hours after going to bed.
1. Does your A-Fib start when you are in a deep sleep (say 3 to 4 hours after going to bed)? If so, you may be able to prevent this by drinking extra water in the hour or so before you go to bed, Inevitably this will ensure you need a toilet break in the middle of the night and cause you to wake up around the danger time for the A-Fib episode. Also consider sleeping cooler as you tend to sleep deeper if you have plenty of blankets on you.
1. If your ectopics continue and you are completely at a loss as to what's causing them, try having a beer - sometimes this can work.
2. If you have an A-Fib episode which has been caused by food, first try settling your stomach (I suggest a Nexium tablet or one or two bananas plus 2 or 3 glasses of water over an hour), and then lie down and go to sleep. Lie down on your back with a slight tilt to the left. Stay still in the same position and relax. The actual reflex which causes you to drift into sleep can be the trigger to terminate the episode.
3. Don't discount the possibility that, if you are taking strong or extended release vitamin supplements, they could be irritating your stomach and making your ectopics worse.
    33. "I have a defective Mitral Valve? Is it causing my A-Fib? Should I have my Mitral Valve fixed first before I have a PVA?"
    Mitral Valve problems seem to be related to A-Fib, possibly because the extra strain a defective Mitral Valve puts on the heart may cause stretching and put extra pressure on the Pulmonary Vein openings where most A-Fib originates. However, fixing your defective Mitral Valve isn’t a guarantee of curing A-Fib. Once the A-Fib hot spots in your heart have been activated, they may continue firing after your Mitral Valve is fixed.
    If you have to have open heart surgery to fix your Mitral Valve, you may want to consider going to a medical center that could fix your Mitral Valve and do a Cox Radial Maze operation at the same time. But bear in mind the Cox maze operation and its less invasive versions are pretty hard on the heart and body.
    If you want to get a PVA to get rid of your A-Fib, you may want to do it before you replace your Mitral Valve. Some doctors will not do a PVA if you have an artificial Mitral Valve, because of the risk of blood clots and the risk of damaging the artificial mitral valve.

    34. "I have silent A-Fib (A-Fib without any obvious symptoms). It was discovered by accident when I was getting an EKG during a physical. Is there any way to tell how often I get A-Fib or how long the episodes last? What kind of A-Fib monitors are available?" (Thanks to Ed Webb for researching and writing this section on A-Fib monitors.)

     The gold standard of A-Fib monitors is called the Holter monitor. You wear this for one or three days. It records signals similar to an EKG.
HOLTER AND EVENT MONITORS

As a general rule, in order to make a diagnosis of an arrhythmia, some form of electrocardiographic recording (i.e., EKG, Holter Monitor, or Event Monitor) must be made at the time the arrhythmia is occurring.

If an arrhythmia becomes persistent and is present day-in and day-out, as often is the case for A-Fib, the diagnosis is quite easy with a routine EKG done in the physician's office. The challenge is when an arrhythmia occurs intermittently (on and off) or is self-limiting, whereby an EKG performed in between onsets can be completely normal. To circumvent this problem, one would go to the next level of evaluation with a long-term monitor.

Long-term monitors basically are EKG recorders that patients can take with them. They fall into two major categories. A Holter Monitor (named after Dr. Norman Holter, go figure) records continuously the EKG of a patient, usually for 24 hours. More modern Holter units record onto digital flash memory devices. The data are uploaded into a computer where software analyzes the input, counting ECG complexes, calculating summary statistics such as average heart rate, minimum and maximum heart rate, and finding candidate areas in the recording worthy of further study. The advantage of a Holter is that every single heartbeat during that day is recorded and can be analyzed. The disadvantage is that if an arrhythmia did not happen on that particular day, the Holter would not be useful.
    An Event Monitor, on the other hand, is a long-term monitor that can be used for up to 30 days or longer. The advantage is that the longer the recording period, the better chance of "catching" an intermittent arrhythmia. The disadvantage is that an Event Monitor must be activated by the patient and downloaded through telephonically, a task that requires a certain amount of manual dexterity and may be difficult for some patients.

Both the Holter and Event monitors record electrical signals from the heart via a series of electrodes attached to the chest. The number and position of electrodes varies by model, but most Holter monitors employ between three and eight whereas the Event Monitors typically use two. This arrangement makes these types of monitors a little inconvenient compared to Sport Heart Rate monitors discussed next.

SPORT HEART RATE MONITORS

Sport Heart Rate Monitors (HRM), which most of you are familiar with, provide a relatively inexpensive alternative to Holter and Event Monitors. The Gold Standard for HRMs is Polar. You can view their range of products at http://www.polarusa.com/us-en/. Other companies include Timex, Garmin, Acumen, Nike, and Cardiosport plus a host of others if you shop around. Personally, I would stick with Polar.

Use of a Sport HRM to detect an episode of A-Fib should not be in lieu of a Holter Monitor or an Event Monitor under physician direction. Rather, they can be used at other times to monitor cardiac progress or for the morbidly curious patients who already have captured sufficient data via the Holter or Event Monitors.

(Melinda Padgett recommends wearing a sports watch to keep track of A-Fib episodes. "It is very enlightening to see A-Fib episodes occur that you can't even feel. Plus the watch helps you keep track of daily A-Fib problems and trends." melinda(at)padgettrealestate.com [When typing this email address, substitute an "@" for the "(at)"---this substitution is necessary to prevent automatic search engines from sending spam to this email address.]}

All of the HRMs rely on the use of a chest strap (can be built into a Jog Bra for women) to pick up the electrical signals from the heart. However, due to the inherent design of the chest strap, the accuracy is somewhat limited and consequently a waveform as recorded by a Holter or Event Monitor is not transmitted to the HRM.

Figure 1

Instead, the HRM keeps track of the R-R interval or the time between R peaks. Without getting too technical, the R peak on a generic ECG waveform (see the Figure 1) corresponds to the ventricle beat (depolarization) and has the largest amplitude (height) of the complete waveform. When the amplitude (picked up as a voltage differential) exceeds a certain threshold, a “beat” is picked up by the chest strap and transmitted wirelessly to the HRM. It is the time between these R peak “beats” that is used by the HRM to determine instantaneous heart rate. It is only going to pick up episodes of Arrhythmia as are manifested in ventricle beats (the R on the waveform). In fact, this is what Polar has to say:

Polar products are not designed to detect arrhythmia or irregular rhythms and will interpret them as noise or interference. The computer in the wrist unit will make error corrections, so that arrhythmia beats are not included in the averaged beats per minute. The blinking heart symbol in the face of the unit, however, will continue to show all heart beats received. In most cases the Polar products will work fine for persons with arrhythmia.

So typically, only insofar as your arrhythmia manifests itself in funky R activity (higher than normal rate) will you see a corresponding readout on the HRM. In this same light, irregular, or unevenly spaced R peaks, will not be picked up by the HRM. This is one of the fundamental differences in how data is recorded between Holter and Event Monitors (actual waveform) compared to HRMs (R-R interval).

(Updated Jan 2011.) Polar has a new line of HRMs, the RS800CX being one, with improved recording capability. Those skipped or extra heartbeats (ectopic) that would have been missed due to lower resolution recording can now be viewed after being downloaded to a PC using Polar software. This information appears as instantaneous heart rate with a resolution of 1 millisecond and so premature or skipped beats associated with heart arrhythmias will be readily apparent.   You can visit this link to see a more detailed explanation of how you can set up and use this new capability: http://www.network54.com/Forum/669782/.

HEART RATE MONITOR RECORDING CAPABILITY

Most HRMs provide some internal storage recording capability. While lower cost HRMs ($100-$150) simply record low, high and average heart rate, upper end models ($200-$300+) allow you to download heart rate data to your PC. On most of the HRMs, you can set a heart rate zone, and the watch will record how long you stayed in that zone.  You could then program a high heart rate zone which you might only enter if you were in A-Fib. That way you could record how long you stayed in A-Fib and what your max heart rate was. This data could be retrieved on the watch itself without having to download it to a PC.

On those HRMs with PC interface capability, you can view data in a graphic form (on some watches you can view the graphic data on the watch itself but with lower resolution.) This could then tell you when you were at a higher heart rate--A-Fib--and how long you stayed there. Of course these kinds of features require some PC skills, but typically the programs are pretty user friendly. See Figure 2 for an example of a Polar PC program.

Figure 2

HANDHELD ECG MONITOR CMS-80A

The CMS-80A Handheld ECG monitor offers a low cost alternative to more expensive devices. It provides single waveform readout from any of the standard 12 leads to help in determining whether you are experiencing a heart arrhythmia.

The CMS-80A is a single channel, 12 lead monitor which can provide data via one of three ways: on the unit display, via the thermal printer internal to the unit or via a USB connection to a PC. The printout from the unit offers the easiest and most accurate means to view lead output. While you can view lead output on the display, you will find that it is not to the same level of detail as the printout. Like most normal ECG monitors, 10 electrodes are attached to the body as follows: 6 suction cup leads to the chest and 4 alligator clip leads to the arms and legs. The unit does not rely on the normal press on style contacts but rather takes a simpler approach with its reusable contacts. Personally, I wasn’t too impressed with the suction cup style contacts as they feel funny and leave a mark as if you had been attacked by an octopus. But they seemed to do the job. The alligator clips, while funky, were quick and easy to attach.

The waveforms presented are not what you would expect from an ECG in your cardiologist’s office, but they can provide the simple basics to make a quick determination whether you are in A-Fib. In particular, by examining the output from Lead II, or perhaps Lead aVF you can quickly observe the absence of a P wave, one sign that you may be in A-Fib. Additionally, examining R-R intervals and whether they are uniformly spaced can be another means to aid in that determination.

From a practical perspective, it could be that you choose to only attach the alligator leads to your arms and legs and forego using the chest leads. You will obviously not have the data from the chest leads (V1 to V6) but that information may not be needed for A-Fib purposes.

The CMS-80A can be purchased through Facelake.com, the sole U.S. distributor for the unit. This is a link to the unit (http://www.facelake.com/ecg-80a.html). Note that the unit is named ECG-80A. More detail to include what the unit looks like can be found on the site.

LifeWatch CG-6108 ACT Wireless Cardiac Telemetry System
    LifeWatch (http://www.lifewatch.com) provides monitoring services for cardiac patients. They have a variety of monitors that they use depending on the individual circumstances and the nature of the data that has been requested from the cardiologist.   Data collected from the monitors is transmitted to LifeWatch via cellular network, the internet or over the phone based on which monitor is being used. Data from the monitors is not intended to be used directly by the patient but rather by the LifeWatch center and cardiologist. The patient would have access to the data from those sources.

   An example of one monitor is the CG-6108 ACT: Ambulatory Cardiac Telemetry - CG-6108 ACT™
The CG-6108 ACT wireless cardiac telemetry system is a 1 and 3-channel
ECG designed for remote arrhythmia monitoring in any location. A small transmitter worn on the patient sends the ECG data to a portable handheld device where it is analyzed. If an arrhythmia is identified, the data is automatically transmitted to a Monitoring Center for immediate review. Integrated into a state-of-the-art mobile phone, the CG-6108 ACT provides next generation cardiac arrhythmia monitoring.

    What’s interesting is the transmitter is a dongle type device worn around the neck with leads placed on the chest. You carry or have available what, in essence, is a mobile phone (it’s actually more than a phone). It is small and not cumbersome. No patient input is required.

    LifeWatch also uses other, more traditional Holter and event monitors, information for which can be viewed on their web site (http://www.lifewatch.com/telehealth_monitors).
    Patients do not work directly with LifeWatch. Rather, LifeWatch solicits physicians to use their services. So, any feedback that a patient receives regarding cardiac status or events would normally come directly from their physician as opposed to LifeWatch.

    This information was provided by Woo Kim at LifeWatch (wkim@LifeWatch.com).

DISCLAIMER. Please keep in mind that you should use a monitor such as this for informational purposes only. Your cardiologist is best able to provide you a more detailed diagnosis based on your individual circumstances.

Email: edandlindafll(at)aol.com (When typing this email address, substitute an "@" for the "(at)"---this substitution is necessary to prevent automatic search engines from sending spam to this email address.)
    35. "I've had Paroxysmal (occasional) A-Fib for a couple of months, but the A-Fib episodes seem to be getting longer and more frequent. I'm worried about going into permanent (Chronic) A-Fib which I know is harder to cure. How long do i have before I go into permanent A-Fib?"
    Worst case scenario, about one year. In a study of 5,000+ A-Fib patients, 54% of those on rate control meds went into permanent A-Fib in one year. ²⁷³
    However, there are people who've had Paroxysmal A-Fib for years and never progress to permanent A-Fib. But the odds are against you. If you don't aggressively try to stop your A-Fib (as with antiarrhythmic meds or a Pulmonary Vein Ablation. etc.), you can expect your A-Fib to become permanent within one year (54% chance).²⁷³

    36. "I definitely have A-Flutter and possibly A-Fib as well. They want to do a Flutter-only ablation on me. Will that help me?"
    Probably not.
    If you have both A-Fib and A-Flutter and have only a Flutter (right atrium) ablation, it's estimated the success rate for curing A-Fib is only between 5 and 10 %.²¹⁹ You're usually wasting your time and undergoing needless risk to do a Flutter-only ablation when you also have A-Fib.
    But what if you have Atrial Flutter and not A-Fib? In this author's opinion, an A-Fib ablation in the left atrium should normally be done at the same time as a Flutter ablation. (A Flutter ablation in the right atrium is relatively simple and doesn't take much time.) Some Flutter may originate in the left atrium, or the Flutter may mask A-Fib which may appear later after a successful Flutter ablation. "Atrial flutter rarely occurs as an isolated rhythm; it is usually associated with atrial fibrillation."²⁶⁵ "As many as half of all patients ablated for Flutter may later develop A-Fib."²¹⁹"A-Fib and A-Flutter tend to coexist...It is not uncommon to find patients who have frequent A-Fib attacks after RF catheter ablation of atrial flutter."²²⁹   A research study atBall Memorial Hospital suggests that anyone with only A-Flutter would be better served by both a Flutter and an A-Fib ablation at the same time.²¹⁹ See Flutter Ablation Should Be Combined With A-Fib Ablation.

    37. "What kind of medical tests will I have to undergo now that I'm being examined for A-Fib?"
    • EKG/ECG Short for Electrocardiogram. A simple, painless test that records a graphical representation of the electrical activity of the heart. 12 sensors placed on different parts of your body record electrical activity from 12 different areas of your heart. An Electrocardiogram is used as an examination tool to determine if you have A-Fib, and can sometimes show a doctor where in your heart an arrhythmia signal is coming from. It's the most useful and most often used test for diagnosing A-Fib.

    The standard ECG records for only a few seconds. For a longer period of time, portable ECG monitors are used.
    • HOLTER and EVENT MONITORS If you have Paroxysmal (occasional) A-Fib, all too often when you're in the doctor's office getting an EKG, your heart is beating normally. But doctors have other means of recording your A-Fib.
    A HOLTER monitor is like a portable EKG that you can wear to record any A-Fib episodes you experience during the day and evening. Small patches on your body are connected to a small, portable recorder.
    An EVENT (LOOP) MONITOR is another type of portable EKG, but it is patient-triggered. When you feel an episode of A-Fib, you press a button to record several minutes of the A-Fib episode. (It's actually recording all the time. When you press the button, it captures some minutes before you press the button and for some time after.) It's called a Transtelephonic Monitor if you call in to transmit the signals you recorded.
    Some Event (Loop) monitors start automatically when they sense abnormal heart rhythms. You don't need to press a button when you feel an A-Fib episode.

    • STRESS TEST You walk (jog) on a treadmill while an EKG records your heart's activity when your heart is working hard and beating fast. Some heart problems are easier to diagnose when your heart is pushed to work hard. This is often combined with Imaging Technologies.
     • ECHOCARDIOGRAPHY (ECHO) (CARDIAC ULTRASOUND) (TRANSTHORACIC ECHOCARDIOGRAPHY) before and after the Stress Test to view and measure heart functions. Echo uses sound waves to create a moving picture of your heart. A transducer on your chest sends special sound waves through your chest wall to your heart. The sound waves bounce off of the structures of your heart, and a computer converts them into pictures on a screen.
    An Echo provides information about the size and shape of your heart and how well your heart chambers and valves are working. It can also identify areas of poor blood flow, areas of the heart that aren't contracting normally or fibrillating, and previous injury to your heart muscle caused by poor blood flow.

    • TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) takes pictures of your heart through your esophagus (the tube leading from your mouth to your stomach). A transducer is attached to a flexible tube that's guided down your throat and into your esophagus. You will be given medicine to numb your esophagus and help you relax. This test may be somewhat painful and cause you to gag. You can ask for stronger sedation to help you get through the procedure. It's usually used just before an ablation to determine if you have blood clots in your atria. If they do find blood clots, you have to be put on anticoagulants to dissolve them before you have an ablation.

    • COMPUTERIZED TOMOGRAPHY (CT) or MAGNETIC RESONANCE IMAGING (MRI)
    Cardiac CT uses an X-ray machine and a computer to take clear, detailed images of the heart and make a three-dimensional (3D) picture of your heart and chest.
    A cardiac MRI uses radio waves, magnets and a computer to create snapshots as well as videos of the beating heart. Just before the MRI they inject you with a dye which can give you a buzz and/or momentary burning feeling which usually goes away rapidly. The MRI is noisy and somewhat confining. You often have to hold your arms above your head as they move your body into a tube around which the magnets rotate. But it doesn't last long.

    • CHEST X-RAY This test can show fluid buildup in your lungs and other complications of A-Fib. You usually shouldn't need a Chest X-Ray. If you are told you need one, ask why. Radiation exposure is considered dangerous and cumulative over time. You should avoid X-Rays whenever possible.

    • BLOOD TESTS You need to be tested for thyroid function, electrolytes, minerals, hormones, etc which may trigger or affect your A-Fib. Nurses need to insert a small needle in your vein and draw off blood. The needle prick can be slightly painful.
    If you are the type of person who has hard-to-find veins (common among older people), ask for the most experienced, best nurse at drawing blood. If necessary, wait for this nurse or come back later when they are around. It may save you multiple needle pricks and bruising.

    • TILT TABLE TEST This test is typically performed to help diagnose the cause of dizziness and fainting. You are placed on a table that tilts upward, and the table is then placed at an approximately upright position so that you are standing. Heart rate and blood pressure are monitored during the test. If no symptoms occur, a medication may be given to increase the heart rate in an attempt to reproduce the symptoms.

    38. "I was hospitalized with A-Fib. My heart beat was very irregular, but it never went above 100 (my normal resting heart beat ranges from 46-54 because I exercise a lot). Is this different physiologically from what most people seem to have? Should the treatment or prevention be any different?" (Thanks to Frank Boyle for this question.)
    It’s not at all unusual for athletes and people in good shape to have a relatively low A-Fib heart rate. When in A-Fib your heart rate may jump from 50 to 100. It’s still bad for you, as you probably felt. But it’s not as bad or dangerous as someone with a really high rate like 200+. (Those kind of high rates can strain the heart, drastically reduce circulation, and can even kill you. People experiencing those kinds of high A-Fib heart rates need to go to an Emergency room ASAP so that doctors can lower their heart rate and/or get them out of A-Fib.)
    You need to be careful about taking most Rate Control and some Antiarrhythmic meds which will lower your heart rate. You can't afford to have your heart rate go any lower. Otherwise you might need a pacemaker to get you out of a too slow heart rate (Bradycardia).
    And be sure you tell doctors, ER, and hospital personnel that you have a naturally low heart rate. Otherwise they will conclude you have Bradycardia and give you a pacemaker.

    If your heart rate only doubles and doesn't go above 100 bpm when you are in A-Fib, consider yourself lucky. But you still have most of the problems and risks of someone in A-Fib. You need to be concerned about an A-Fib stroke, your heart isn't pumping properly, etc.
    Your treatment options are basically the same as someone with higher A-Fib heart rates. However, you do have more of an option to just live with your A-Fib, assuming your A-Fib symptoms aren't too bad.

    39. "How does age affect A-Fib? I've heard that you can't get an A-Fib ablation if you're too old."
    The older you are, the more likely you are to get A-Fib. One out of four people over 40 will get A-Fib in their lifetime.⁸² As patients get older, the prevalence of A-Fib increases, roughly doubling with each decade. 2-3% of people in their 60s, 5-6% of people in their 70s, and 8-10% of people in their 80s have A-Fib.^68,69,70 This suggests that A-Fib may be related to degenerative, age-related changes in the heart.
    How old you are also affects what treatments will work for you. If you're young and/or an athlete and/or in special occupations like a pilot, you may be given a Pulmonary Vein Ablation (PVA) as a first option. Young people can't be expected to live the rest of their lives on rate control or antiarrhythmic meds, while people like athletes and pilots need to be A-Fib free to perform and to pass medical tests.
    Even though A-Fib affects mostly older people, if you're over 80 years old, many centers will not accept you for a PVA. The reason is older people tend to be more frail and more prone to complications. You will probably be given meds as your only therapy choice. See the FAQs question "I'm eighty years old and in Chronic A-Fib fro three years."
    But not all centers have this policy. The author has heard of people in their 90s getting a successful A-Fib ablation.
    If you're under 80 years old, you will probably be given antiarrhythmic meds as a first option (rate control meds ordinarily don't stop A-Fib but only keep your heart from beating too fast). You will have to try them for six months to a year before you can have a PVA. But if you don't want to be on antiarrhythmic meds for that long a time, you can opt for a PVA right away. But you may have to be very assertive and insist that you don't want to take antiarrhythmic meds.

40. "I'm scheduled to have Mini-Maze surgery. During the operation they close off the Left Atrial Appendage (LAA) to prevent clots and stroke. But a friend of mine had his LAA closed off, and now he can't exercise like he used to. Does closing off the LAA hurt the heart?"
Reasons to Close Off the left Atrial Appendage
    The rationale for closing off the LAA is that, in case the Mini-Maze fails which doesn't often happen, the patient is still protected from having an A-Fib stroke. 90%-95% of A-Fib strokes come from clots that originate in the LAA. In A-Fib, blood stagnates in the LAA and clots tend to form.
    Another important consideration is that closing off the LAA, even if a person is no longer in A-Fib, may still prevent a stroke. The LAA is where most clots originate. If a surgeon is already working on the heart, why not close off the LAA and reduce the patient's chance of having a future stroke? (If they didn't close off the LAA, they could be sued if a patient later had a stroke, even if the patient was no longer in A-Fib.) Life (no stroke) is more important for most people than a possible reduced exercise intolerance.
    In the future even people without A-Fib may have their Left Atrial Appendage closed off if it prevents or reduces the risk of a stroke. There are currently a variety of devices, surgical and non-surgical, which can do this.
Functions of the Left Atrial Appendage
    The LAA functions like a reservoir or decompression chamber or a surge tank on a hot water heater to prevent surges of blood in the left atrium when the mitral valve is closed.²⁸⁶ Without it there is increased pressure on the pulmonary veins and left atrium which might possibly lead to heart problems in the future.
    Cutting out, stapling shut, or closing off the LAA also may reduce the amount of blood pumped by the heart and may possibly result in exercise intolerance for people with an active life style. (In dogs the LAA provides 17.2% volume of blood pumped.²⁵⁷)
    The LAA also has a high concentration of Atrial Natriuretic Factor (ANF) granules which help to reduce blood pressure.287
    But these functions for most people aren't nearly as important as reducing the threat of a stroke.

The following questions deal with Medications for A-Fib.

    41. "Which medications are best to control my Atrial Fibrillation?" "I have a heart condition. What medications work best for me?"
     In general, current medications don't always work on A-Fib. What medications are best for you is a judgment call only you and your doctor can make.
    People tend to react differently to meds. What works for one person may be terrible for another.
    When trying a new med, there is a fine line between on the one hand allowing time for your body to adjust to it, and on the other hand recognizing that this drug is causing bad, unacceptable side effects.
    When starting a new med, your doctor may hospitalize you in order to monitor how the drug affects you.
     If you've just been diagnosed with paroxysmal (occasional) A-Fib, flecainide (brand name Tambocor) might work for you. Some people have had good luck with the relatively new drugs dofetilide (brand name Tikosyn) and Rhythmol SR (propafenone). The newest antiarrhythmic med is Multaq (dronedarone) which is a less toxic substitute for amiodarone. See Medications.
    Here is a set of guidelines from the ACC/AHA/ESC based on one's overall heart health. (This is based on Dr. Eric Prystowsky's presentation at the 2003 Boston A-Fib Symposium.)
    1. Minimal or no heart disease. Flecainide, propafenone, sotalol. The object is to "minimize organ toxicity," to select drugs that will not harm the rest of the body. The above drugs can cause "proarrhythmia" (an increase in heart rhythm problems), "but in patients without heart disease, this risk is extremely small."
    If these drugs don't work, then dofetilide and amiodarone can be considered. And "in experienced hands one might choose (Pulmonary Vein) Ablation (Isolation) for a primary cure."
    2. Congestive heart failure. Only dofetilide and amiodarone have been demonstrated to be safe in randomized trials.
        a) Congestive heart failure and significant lung disease. "I would likely consider dofetilide as my first choice."
        b) Congestive heart failure who are "hypokalemic" (have low levels of potassium). Amiodarone.
    3. Coronary artery disease. Sotalol is recommended because of its beta blocking and antiarrhythmic effects. Amiodarone or dofetilide combined with a beta blocker can also be used. Propafenone and flecainide aren't recommended.
    4. Hypertension. Propafenone or flecainide.
        a) Hypertension and substantial left ventricular "hypertrophy" (increase in size). Amiodarone, because it has the least proarrhythmic effect.

    42. "Is the "Pill-In-The-Pocket" treatment a cure for A-Fib? When should it be used?"
    The "Pill-In-The-Pocket" treatment refers to taking an antiarrhythmic med at the time of an A-Fib attack.
    One approach is to take 100 mg of flecainide up to three times at 20 minute intervals to stop or shorten an A-Fib episode.
    Another approach is to take Rythmol 300 mg and Inderal 20 mg, wait three hours, then take Inderal 20 mg, wait three hours, then take Rythmol 300 mg and Inderal 20 mg again. (Other meds and dosages are used depending on the needs of the patient).
    Another variation of the "Pill-In-The-Pocket" treatment is to take an antiarrhythmic med on a regular basis, then take an higher dose at the time of an A-Fib attack. Reg writes he takes 300 mg of flecainide, and 2 hours later goes back into SR. He normally is on a loading dose of flecainide 100 mg in the morning and 50 mg in the afternoon. (Email: r.j.tooth (at) shu.ac.uk. The "@" is written as "at" to prevent access by automated spam lists.)
    In this author’s opinion, the ideal use of an antiarrhythmic med is to take it on a regular basis to keep one from having an A-Fib attack. Taking an antiarrhythmic med only when one has an A-Fib attack is like trying to put out a fire after it has started. From a patient’s perspective, it’s better to keep A-Fib from starting in the first place, to be proactive rather than reactive.
    However, not everyone can tolerate antiarrhythmic meds on a regular basis. The Pill-In-The-Pocket treatment is an excellent, welcome option for A-Fib patients who feel bad when taking antiarrhythmic meds every day.
       (When the author had A-Fib, he never tried the "Pill-In-The-Pocket" treatment. He welcomes comments and corrections to this opinion.)
    The "Pill-In-The-Pocket" treatment should probably not be considered a "cure" for A-Fib, but more of a help to get one out of or shorten an A-Fib attack. See "PILL-IN-THE-POCKET" TREATMENT and TWO DIFFERENT "PILL-IN-THE-POCKET" APPROACHES---BOTH TURN TO CATHETER ABLATION FOR A CURE.

    43. "I take atenolol, a beta-blocker. Will it stop my A-Fib."
    Not usually. Beta-blockers like atenolol, calcium channel blockers, and digitalis compounds are rate-control medications. They attempt to control your heart rate (ventricular beats), but leave your heart in A-Fib. "In fact, these (rate control) drugs, which are quite valuable in achieving ventricular rate control, have not been shown in placebo-controlled studies to restore sinus rhythm."¹⁰⁹
    If you are under the impression that atenolol or other rate control drugs will stop your A-Fib, it might be wise to check with your doctor or get a second opinion.
    However, we all react somewhat differently to meds. A drug that doesn't work for one person may be very effective for another.

    44. "I've been on amiodarone for over a year. It works for me and keeps me out of A-Fib. But I'm worried about the toxic side effects. What should I do?" (Thanks to Lee Abdullah for this question.)
    You are correct to be concerned about toxic effects. Amiodarone is considered one of the most effective antiarrhythmic meds, but it's also one of the most toxic. It may affect your lungs, eyes, thyroid, liver, skin, heart, and nervous system. (For a more detailed medical description of these effects, see "Screening and Management of Amiodarone Toxicity" by Heist and Ruskin.)
    Also, amiodarone has a long half life———it is retained in the body for up to 45 days after the drug has been discontinued.²²⁵
    (Be advised that a newer drug dronedarone (brand name Multaq) is now on the market and may be a good substitute for amiodarone. Dronedarone may not be quite as effective as amiodarone, but is much safer.)
    If you are taking amiodarone, you should by monitored and tested frequently and scrupulously for damage to your organ systems (your doctor may already be doing this). You should keep copies of any tests. What's important is not so much whether you are within a "normal" range, but whether your measurements are going up and how fast. Note: it's important that baseline values for organ systems should be documented before you start taking amiodarone.
    Contact your doctor immediately if, after taking amiodarone, you experience any new symptoms such as: coughing, wheezing, shortness of breath, visual changes, skin rash, pain, tingling or weakness in the arms or legs, fever, rapid heart beat, fatigue, lethargy, unusual weight gain, swelling, hair loss, cold or heat intolerance, lightheadedness or fainting.
    The recommended maintenance dose of amiodarone is 200 mg/day.²²⁵A possible toxic level of amiodarone may be 400 mg daily for more than two months, or a low dose for more than two years.225

lungs
    Perhaps the most important test is for the lungs. "Amiodarone-induced pulmonary toxicity can be progressive and fatal if not recognized and treated."¹⁵⁷See also Death from Amiodarone? You should have a chest X-Ray and Pulmonary function testing with diffusion capacity (DLCO) before starting and at least every year you are on amiodarone.

thyroid
    Thyroid problems from amiodarone are all too common and can occur in as many as 22% of patients.¹⁵⁷Decreased energy, cold intolerance and weight gain are among the most common effects of decreased thyroid function. You should test for blood levels of TSH (Thyroid Stimulating Hormone), as well as the thyroid hormones free T4 and total T3. Amiodarone can also increase thyroid function with symptoms such as atrial rhythm disturbances, elevated heart rate, heat intolerance, and weight loss.

EYES
    Corneal microdeposits occur in the majority of patients who take amiodarone, but they usually don't cause any ill effects. More substantial microdeposits, however, can cause visual disturbances and even severe damage/inflammation of the optic nerve which can cause blindness. On taking amiodarone, you should have yearly eye exams. Report any visual changes immediately to your Electrophysiologist.

LIVER
    Amiodarone commonly causes liver toxicity, but usually only mild increases in blood liver function tests (LFTs). The liver function tests are AST (SGOT), ALT (SGPT), and bilirubin. More severe cases can result in liver failure signaled by jaundice, abdominal pain, and distension.

SKIN
    Amiodarone increases sensitivity to the sun and sun burning. This increased sensitivity to the sun can be severe in approximately 10% of patients. Avoid the sun, apply sunscreen, and wear additional clothing.
    It also can produce a blue or gray discoloration of the skin if one takes heavy doses and/or for long periods. This discoloration can persist after stopping amiodarone, but may fade very gradually (often years) after drug discontinuation.

HEART
    Amiodarone can cause slow heart rhythm disorders such as slowing of the sinus rate and AV block. You may feel fatigued, lethargic, have poor exercise tolerance, and may experience dizziness and fainting. Less commonly, amiodarone may induce ventricular arrhythmias such as polymorphic ventricular tachycardias called "Torsades de Pointes" or TdP which can cause death.
    You should have a 12 lead EKG before starting amiodarone and at six-month intervals in order to assess baseline heart rate, rhythm, and EKG signal intervals (PR, QRS, QTc). See EKGsignal.

NERVOUS SYSTEM
    Amiodarone can produce peripheral neuropathy---decreased sensation, pain, clumsiness or weakness, especially in the arms, hands, legs and feet. Neuropathy exams should be performed during follow up visits at approximately six-month intervals.

fetus/nursing infant
    Amiodarone is known to cross the placenta and enter the fetus, and is excreted in breast milk. Use of amiodarone should be avoided if at all possible in women who are pregnant or likely to become pregnant. Lactating women who are taking amiodarone should not breastfeed. Due to the likelihood of toxicity if amiodarone is taken for decades, amiodarone use is strongly discouraged in children, unless there are no acceptable alternatives.¹⁵⁷

    Warfarin (Coumadin) questions

(Added 11/30/10:) The FDA recently approved a new blood thinner called dabigatran (brand name Pradaxa) which is as effective or even more effective than warfarin without many of the accompanying problems of warfarin. It will probably replace warfarin as the blood thinner of choice for A-Fib. See Dabigatran to Replace Warfarin and Dabigatran Now Available in Pharmacies.
    Dabigatran (brand name Pradaxa) is a direct thrombin inhibitor, a newer type of medication. Thrombin is an enzyme that converts soluble fibrinogen into insoluble fibrin. Fibrin is a fibrous protein involved in the clotting of blood. It forms a mesh or clot over a wound.

   45. "Should anyone who has A-Fib be on the blood thinner warfarin (Coumadin)?"
    Not necessarily. See the following question "Which is the better anticoagulant to prevent stroke?" See also an up-to-date examination of research on this subject in MEDIFOCUS Atrial Fibrillation "Anticoagulants for Stroke Prevention in People with Atrial Fibrillation."

   46. "Which is the better anticoagulant to prevent stroke---warfarin (Coumadin) or aspirin? What's the difference between warfarin and Coumadin?" (Added 11/30/10:) The FDA recently approved a new blood thinner called dabigatran (brand name Pradaxa) which is as effective or even more effective than warfarin without many of the accompanying problems of warfarin. It will probably replace warfarin as the blood thinner of choice for A-Fib. See Dabigatran to Replace Warfarin and Dabigatran Now Available in Pharmacies.
    Dabigatran (brand name Pradaxa) is a direct thrombin inhibitor, a newer type of medication. Thrombin is an enzyme that converts soluble fibrinogen into insoluble fibrin. Fibrin is a fibrous protein involved in the clotting of blood. It forms a mesh or clot over a wound.

   Aspirin is an antiplatelet drug that decreases the stickiness of circulating platelets (small blood cells that start the normal clotting process), so that they adhere to each other less and are less likely to form blood clots. Whereas warfarin (brand name Coumadin) is an anticoagulant that works by slowing the production of blood clotting proteins made in the liver. However, "current research indicates that aspirin is not as effective in preventing blood clots (and therefore, strokes) as Coumadin."³⁶ "...while warfarin is highly effective, reducing the annual risk of stroke by approximately two thirds, aspirin has a more modest 20% effectiveness rate."⁴⁵ But aspirin is less likely to cause abnormal bleeding than warfarin.
    People with less risk factors for stroke are often on aspirin. People more at risk for stroke such as those over 65 years old with frequent A-Fib episodes are often on warfarin (Coumadin) (baring other risk factors such as Peptic Ulcer, etc.). In such cases the relative risk of stroke exceeds that of bleeding by approximately 85%.^37,56 However, it should be noted that the risk of hemorrhagic stroke increases with age and is also increased by taking warfarin (Coumadin). For this reason some doctors switch older patients from warfarin (Coumadin) to aspirin. (But see Bleeding Risk from Warfarin where Dr. Waldo disagrees with this practice.) Also, a recent study Warfarin bests aspirin for stroke prevention in elderly A-Fib patients found that with A-Fib-ers over 75 years old "warfarin was superior to aspirin for primary stroke prevention without a significant increase in hemorrhage risk." A more recent study found that, "...age should not be a barrier to warfarin treatment...that the benefit of warfarin is highest...in the very old."¹⁵⁸
    Doctors use what is called a CHADS2 stroke-risk grading system to help determine what blood thinner to use.
- "C" Congestive Heart Failure Score = 1
- "H" Hypertension Score = 1
- "A" Age over 75 Score = 1
- "D" Diabetes Score = 1
- "S2" Previous Stroke or TIA Score = 2
A CHADS2 score of 2 or over would indicate someone should be on warfarin.
    But younger people with a low risk of an A-Fib stroke "appear to derive little benefit from warfarin. And, indeed, warfarin may do more harm (intracranial hemorrhage) than good (prevention of ischemic A-Fib stroke)."¹⁸⁶
    Weighing the various risk/benefit ratios is a decision for you and your doctor and may change in life as you do.

What's the difference between warfarin and Coumadin?"
    "Warfarin" is the name of the generic medication, whereas "Coumadin" is the Brand name. In general, generic medications are very similar to the Brand name medications. But there is anecdotal testimony that Coumadin may be more effective than warfarin. It's up to you and your doctor to determine which is better for you. (Oral anticoagulants like warfarin are also called "vitamin K antagonists," since they work by counteracting the coagulation vitamin K.)
    Warfarin (Coumadin) must be maintained at a proper level in your blood to be effective. A test called Prothrombin Time (ProTime, PT) is used to determine the INR (International Normalized Ratio) of warfarin in your blood to determine how quickly your blood clots. It should be between 2.0 and 3.0. Above 4.0 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.
    It is often difficult to maintain this INR, especially when you first start on warfarin. You may have to take sometimes weekly PT tests in your doctor's office till you get the warfarin dosage and INR right. There are home use kits available for testing your own INR (for example, see http://www.PTINR.com}.
    If your doctor prescribes warfarin (Coumadin), you probably should be tested for variations in the CYP2C9 and VKORC1 genes which influence how you respond to warfarin. If your doctor doesn't provide this testing, you may want to think about getting a second opinion. This testing could save you from heart problems related to under- and over-dosing of warfarin.

47. "I'm on warfarin. Can I also take aspirin, since it works differently than warfarin? Wouldn't that give me more protection from an A-Fib (ischemic) stroke?"
    No. Preliminary research indicates that combining anticoagulants (warfarin) and antiplatelets (aspirin) in the same patient is associated with a substantially higher risk of fatal or non-fatal internal bleeding. And there was no indication that combining warfarin with an antiplatelet (aspirin, clopidogrel, or both) reduced the risk of ischemic stroke.

48. "What are my chances of getting an A-Fib stroke?"
    The Center for Shared Decision Making gives somewhat controversial odds of getting an A-Fib stroke depending on one's overall heart health (http://www.dhmc.org/webpage.cfm?site_id=2&org_id=108&morg_id=0&sec_id=0&gsec_id=39685&item_id=39691):
    Under age 65 with no history of hypertension, stroke, arterial embolism, left ventricular dysfunction, or TIA:
        Chance of stroke in two years 2 out of 100
        Taking daily coated aspirin 1.5 out of 100
        Taking daily warfarin 1 out of 100
    Age 65-75 with no history of hypertension, stroke, arterial embolism, left ventricular dysfunction, or TIA:
        Chance of stroke in two years 4 out of 100
        Taking daily coated aspirin 3 out of 100
        Taking daily warfarin 2 out of 100
    Over age 75, or under age 75 with history of hypertension or left ventricular dysfunction:
        Chance of stroke in two years 12 out of 100
        Taking daily coated aspirin 9 out of 100
        Taking daily warfarin 4 out of 100
    Any age with a history of TIA, stroke or arterial embolism, or over age 75 with a history of hypertension or left ventricular dysfunction:
        Chance of stroke 20 out of 100
        Taking daily coated aspirin 16 out of 100
        Taking daily warfarin 7 out of 100

    49. "I'm worried about having to take the blood thinner warfarin (brand name Coumadin). If I cut myself, do I risk bleeding to death?"
    In general, no. On a normal dosage of warfarin (Coumadin) you will bleed longer if you cut yourself (not a serious wound). But your blood will still clot. You will also bruise more easily.
    You should stay away from contact sports like hockey, football, rugby, etc. or activities where you could easily injure yourself like mountain climbing, competitive biking, etc. Professional athletes should not be on warfarin (Coumadin).
    But you can do normal daily activities on warfarin. However, in case of an emergency, you may want to get a Medical ID Alert to warn paramedics and doctors that you are taking a blood thinner.
    If you are in an accident and are bleeding profusely, doctors will check your INR and administer fresh frozen plasma (FFP) which has clotting factors. (Fresh frozen plasma is the liquid portion of human blood that has been frozen and preserved quickly after a blood donation.)

    50. "I am on Coumadin (warfarin) to thin my blood and prevent A-Fib blood clots. Do I now need to avoid foods with Vitamin K which would interfere with the blood thinning effects of Coumadin?" (Thanks to Ruth McKee for the suggestion of this question.)
    No. Vitamin K is an important nutrient, especially for bone health.¹⁵⁵ You should instead try to maintain a consistent intake of vitamin K through food and/or supplements. You should maintain at least the U.S. recommended amounts of Vitamin K (120 mcg/day for men, 90 mcg/day for women¹⁵⁵).
    Your liver uses vitamin K to make blood clotting proteins. Coumadin lowers your risk of forming a blood clot by reducing the liver's ability to use vitamin K to produce these blood clotting proteins. But you still need vitamin K for your overall good health. A lack of vitamin K, for example, can lead to osteoporosis.¹⁵⁵
    Let's say you have low levels of vitamin K. If you then eat a spinach salad or liver which are high in vitamin K, this will cause a huge increase in vitamin K intake and consequently a significant drop in your INR (the amount of thinning of your blood). But if you consistently have normal (or preferably higher) levels of vitamin K, a spinach salad or liver will not cause a huge increase in vitamin K.
    When starting Coumadin, you should talk over with your doctor how to maintain a consistent diet and/or supplement level of vitamin K. This is especially important if you change your diet. Ideally you should consult your doctor before making any major changes in your diet and vitamin K intake.

    51. "The A-Fib.com web site claims that an A-Fib stroke is often worse than other causes of stroke. Why is that? If a clot causes a stroke, what difference does it make if it comes from A-Fib or other causes? Isn't the damage the same?"
    Poor stroke outcome may be due to a reduction in cerebral blood flow caused by A-Fib.
    But a more important factor may be the size of the clots that form in the Left Atrial Appendage. 95% of A-Fib strokes may come from the Left Atrial Appendage (LAA). Clots that form in the LAA can be quite large and completely block blood vessels in the brain often resulting in death or severe neurologic damage. The slides below show clots formed in the Left Atrial Appendage and demonstrate how large they can become. Clots from other causes may not be as large and may not cause as much damage.

http://www.strokecenter.org/education/albers/af1_p6.htm

Notes:
The left atrial appendage of a woman with atrial fibrillation who suffered a thromboembolic event is shown. Organized 5mm thrombi are apparent. A 5mm thrombus can completely occlude the middle cerebral artery.

Copyright (1988) American Heart Association.
http://www.strokecenter.org/education/albers/af1_p7.htm

    52. "I just had an Electrical Cardioversion. My doctor wants me to stay on Coumadin for at least one month. Why is that required?
    They mentioned something about a "stunned atrium." What is that?" (Thanks to David Mobley for this question.)
    A "stunned atrium" is medically defined as a "state of temporary mechanical atrial dysfunction with preserved bioelectrical function"¹⁷⁸---in non-medical terms your heart doesn't contract properly even though is it getting the right electrical and chemical signals to contract. This can happen after an Electrical Cardioversion and is why the left atrium and, in particular, the Left Atrial Appendage tend to develop clots after an Electrical Cardioversion.
    The Left Atrium, and especially the Left Atrial Appendage, is "stunned" after the electrical shock and may not contract and pump out properly. Clots can develop and be released when the LAA starts to contract again.¹⁷⁹ That's why you need to be on a blood thinner like Coumadin for a month after your Electrical Cardioversion.

    53. "I know I'm at risk of an A-Fib stroke, but I hate taking Coumadin. Aren't there any natural remedies or supplements I could take?"
    There are "natural" remedies that thin the blood. But there isn't much research on their effectiveness in preventing an A-Fib stroke.
    Realize also that your doctor isn't likely to tell you to stop taking prescription blood thinners like Coumadin (warfarin) and Plavix. That would be legal suicide. Even people on Coumadin with the proper INR levels get strokes. Coumadin reduces the annual risk of A-Fib stroke by two-thirds,⁴⁵ but it doesn't eliminate it entirely. However, if your doctor took you off of Coumadin and you had a stroke, he/she could be sued.
    The same is true for this web site which is not recommending or suggesting you quit taking prescription blood thinners.
    Here are two "natural" remedies that are thought to thin the blood. Again, how effective these "natural" blood thinning regimens are to prevent A-Fib stroke has not been scientifically established.

Gingko 120 mg once or twice daily
Essential Daily Defense (Garry Gordon's Product) 3-4 3 times daily (Contains Niacin, Vitamin B-6, Garlic Powder, Calcium Disodium EDTA, MSM, Malic Acid, Betaine HCL, Papain, Silica, Red Yeast, di-Methionine, Beta Sistosterol, Crataegus 6x (Hawthorne Berry), Carrageenan (Red Yeast)
Nattokinase or Lumbrokinase 2-6/day depending on circumstances
Unique E 1200 IU daily
Omega 3/6 2 twice/day

    Another similar regimen is the following:

    Nattokinase 1 2-3 times a day
    Fish Oil 2 capsules twice daily
    Gingko capsules 2-4 times a day
    Garlic (Kyolic) capsules 2-4 times a day
    Delta Tocotrienols 100 mg daily

    54. "Someone suggested I get a Watchman device installed or go through surgery to close off my Left Atrial Appendage (LAA), so that I don't have to take Coumadin or other blood thinners. But will closing off or removing the LAA affect how well my heart pumps, my athletic performance (I'm a professional athlete)?"
    I don't have a definitive, scientifically tested answer for you. But in canine studies the LAA provided 17.2% of the whole left atrial volume of blood pumped.²⁵⁷ Intuitively I would think losing 17% of left atrial blood pumped would affect a professional athlete's performance.
    But what about an older AFib patient who doesn't want to spend the rest of their life on blood thinners? To this author the reduced pumping volume of the left atrium is a small price to pay compared to the threat of an ischemic stroke which can be a fate worse than death.
    But it is possible that removing or closing off the LAA may lead to heart pumping problems? Many people have had surgical removal of the LAA or the Watchman device installed and don't seem to complain about reduced pumping efficiency of the heart. But this is at best anecdotal evidence which doesn't carry a lot of weight. We need further studies to determine how the reduced atrial blood flow does affect overall health and heart health.

    The following questions deal with Pulmonary Vein Ablation (Isolation) procedures.

    55. "I'm getting by with my Atrial Fibrillation. With the recent improvements in Pulmonary Vein ablation techniques, should I wait till a better technique is developed? What improvements are being developed? Are any worth postponing an A-Fib ablation I have scheduled?" (Thanks to Tom Price for this question.)
    In general I wouldn't wait on having a PVA. A-Fib is a progressive disease that tends to get worse over time. In a process called "remodeling" your heart may change physically and electrically if you have A-Fib long enough. It's important to be cured as soon as possible. See Overview. For example, in a year you have approximately a 50% chance of moving from Paroxysmal (occasional) to Persistent/Chronic which is harder to cure.¹⁶⁴
    Current RF Ablation techniques are very effective. Many doctors have years of experience doing them. In this author's opinion, current innovations being developed aren't going to be major game changers. But this is a decision your and your doctor need to make.
    With today's current Pulmonary Vein Ablation (Isolation) procedures using Radio Frequency Catheters, you have an 75-85% chance of being cured permanently (in cases of Paroxysmal A-Fib).^17,41 (The other 15% often are significantly improved, if not permanently fixed.) Your odds aren't going to get much better than that.

A-FIB INNOVATIONS
    Here is a description of some of the new technologies being developed or actually in use today (February 19, 2011). See if you and your doctor think any of them are worth waiting on. But some are in clinical trials and may take a long time to get FDA approval (or the FDA may not approve them at all). It's not like waiting on next year's model of a car. For a more detailed look at these new technologies, see Drs. Burkhardt and Natale's article²³⁴ from which most of this answer is taken. http://circ.ahajournals.org/cgi/content/full/120/15/1533?eaf

IMAGING TECHNOLOGIES
    Most of the imaging technologies described here are in use today and represent huge advances in patient treatment.
    Ordinary ablations use Fluoroscopy, a type of X-ray to see inside and ablate the heart. But it is two dimensional. Intracardiac Echocardiography (Ultrasound) (ICE) is also 2-D but provides excellent anatomic detail and assistance in navigating and positioning the catheter. Electroanatomic Mapping (EAM) offers a 3-D view both outside and inside the heart in almost real time. New technologies combine both of these technologies. CartoSound (Biosense Webster, Cincinnati, OH) uses a proprietary 3D EAM system and incorporates the information obtained from an intracardiac ultrasound probe to visualize and map the heart. (3-D intracardiac ultrasound probes are being developed which would provide real-time 3-D imaging and navigating.)

    CartoSound (Biosense Webster, Cincinnati, Ohio).
Left, ICE image with a contour drawn around the atrial border and pulmonary vein.
Right, EAM integrated onto a live ICE image.

    From a patient's perspective, should you try to find a larger facility that has CartoSound rather than one that only uses 2-D fluoroscopy? Doctors using CartoSound would seem to have better imaging tools to do ablations. But doctors using fluoroscopy also get good results.
    Computed Tomography (CT) can also be used to obtain detailed images of the left atrium. Rotational Angiography uses standard fluoroscopic equipment to obtain 3-D CT-like images while rotating around the patient.

A 3-D reconstruction of a left atrium obtained by rotational angiography.
LAO indicates left anterior oblique.
RAO right anterior oblique
CRAN cranial
CAUD caudal

Rotational Angiography is currently not in wide use.

BALLOON CATHETERS
    CRYOBALLOON CATHETER
    In this author's opinion, one of the most exciting, important new technologies for A-Fib patients is the recently FDA approved CryoBalloon Catheter. The balloon system can be used to fit into a Pulmonary Vein opening, then ablate it with a minimum number of lesions. This could be a vast improvement over current RF catheters which use pinpoint lesions to perform large-area ablations in a point-by-point fashion and which require a great deal of operator skill and manual dexterity. CryoBalloon ablations might become easier and faster to do than RF.
    Using the energy source Cryo to make ablations may also be a major improvement for A-Fib patients. Cryo uses very cold temperatures to freeze tissue to create lesions without the vaporization, charring, and tissue damage of RF. It preserves heart tissue integrity rather than burning it. When cold temperatures are applied, Cryo catheters stick to the heart tissue they touch, much like a tongue on cold metal. Since the heart is beating and in constant motion during an ablation, this is a significant advantage. And Cryo produces no crust formations. RF burns can cause a crust to form over the ablated area (called a "thrombus"). This crust can fall off and lodge in a blood vessel, perhaps causing a blood clot and stroke. (That’s one of the reasons blood thinners like heparin are used during RF ablations, to prevent these blood clots.) In the clinical trials, the CryoBalloon catheter was safer for patients. There were no strokes, no pulmonary vein stenosis, no esophageal injury, and no coronary artery injury as sometimes occurs with RF ablation. http://www.theheart.org/article/877315.do There is also little danger of perforation and tamponade with the CryoBalloon catheter. (Added 3/7/11: Results from the North American Arctic Front STOP-AF trial did show a PV stenosis rate of 3.1% which did not show up in the European trials. This may have come from the use of a smaller 23 mm balloon which possibly penetrates too far into the Pulmonary Vein opening.)²⁴² To see a video demonstration of the CryoBalloon Catheter, go to http://www.cryocath.de/en/4.products/af.presentation.asp
    But preliminary anecdotal comments from doctors indicate that Cryo ablations may have more reconnection/reconduction problems than RF (perhaps because Cryo doesn't damage heart tissue as much as RF). And the two sizes of Cryo balloons don't always fit neatly into pulmonary vein openings. The Cryo (freezing) can affect the Phrenic Nerve and cause breathing problems, but these usually resolve over time.²³⁹ (Added 3/7/11: The North American Arctic Front STOP-AF trial showed a Phrenic Nerve Palsy (paralysis, weakening) of 11.2 %. Some of these cases did not resolve within 12 months (18 %). This Phrenic Nerve damage may have come from the use of the smaller 23 mm balloon which gets closer to the Phrenic Nerve. Dr. Kuck has had good results (no PV stenosis) using only the larger 28 mm balloon.⁾²⁴²
    The CryoBalloon catheter has to be withdrawn and RF or Cryo non-balloon catheters inserted to "touch up" areas the balloon catheter missed, which often requires considerable time and more fluoroscopy exposure. This also increases the cost of an A-Fib ablation, so that hospitals and insurance companies may actively discourage the use of additional catheters.
    However, with more experience doctors may overcome these problems.
    (The CryoBalloon catheter may be a "Gateway Technology" allowing many more doctors to enter the field. The number of A-Fib doctors today can take care of less than 1% of the A-Fib population annually.²³⁶ An increase in the number of doctors able to perform successful A-Fib ablations would be a major help in our current A-Fib epidemic.
    But in these first days of CryoBalloon ablation, patients should be cautious and seek out high volume, experienced centers.)

    LASER BALLOON CATHETER
    The variable size balloon of the Laser catheter (CardioFocus, Inc., Marlborough, MA) can be positioned in a vein opening to encircle the vein. Two overlapping laser energy ablations can usually completely isolate the vein without any gaps. The catheter features direct visualization (endoscopic). The doctor sees directly through the catheter the area he/she is ablating. Though the Laser Balloon Catheter is probably years away from FDA approval, it may have more potential than the CryoBalloon catheter. The variable size of the Laser Balloon makes it easier to manipulate and might enable it to fit better into the different sizes of pulmonary vein openings. Laser energy might produce more lasting lesions than Cryo. And direct visualization would certainly be a help to doctors doing an ablation and would reduce the amount of radiation patients and medical staff are exposed to.

This is an example of what the doctor sees. "LSPV" is the Left Superior Pulmonary Vein, "LIPV" is the Left Inferior Pulmonary Vein.
http://www.cardiofocus.com/pdf/Schmidt_CircEP_Laser.pdf

    MULTIELECTRODE RF ABLATION CATHETERS
    These circular and mesh array shaped catheters are also probably years away from FDA approval. Like balloon catheters they can fit into a pulmonary vein opening and isolate the opening in two or more passes. These catheters also offer ablation at specific poles to produce pin-point ablation of A-Fib spots in the heart. Currently none of the versions offer internal or external irrigation. (Most RF catheter ablation today uses open irrigation to cool the catheter tip, which allows more energy to be delivered without the limitation of overheating the catheter tip.)

FORCE-SENSING TECHNOLOGIES
    It's been discovered that the force applied to heart tissue during RF ablation affects the size and safety of the lesions. Too little force results in lesions that are smaller in volume and depth and may not be effective. Too much force can result in pressure- and overheating-related complications such as steam pops, coagulum formation, or charring at the electrode. In worst cases they can lead to perforation and/or stroke. (That's why A-Fib patients are advised to seek out A-Fib doctors with experience who perform enough ablations a year to maintain and develop the "touch," manual dexterity, and skill necessary to produce good ablations. Unlike other arrhythmias, A-Fib ablation requires greater technical skill, more time, and more lesions.) New force-sensing technologies help doctors apply appropriate force. Sensors on the catheter give instantaneous feedback on the force applied at the catheter tip and even the angle of the catheter.

The Contact Force Sensor Catheter (TactiCath, Endosense, SA) uses three optical fibers to measure "microdeformation"---how much the catheter tip bends when pressed against heart tissue. The force applied changes the wavelength of light in the optical fibers. The force applied during an ablation shows up on a imaging/mapping system as either yellow, green or red. Doctors can see when they make an ablation how much force they applied to a particular spot.

REMOTE CONTROL ABLATION---HANSON, STEREOTAXIS
    REMOTE ROBOTIC NAVIGATION
    In manual ablation the doctor controls the catheter tip by a combination of plunger movements, rotation, and advancing and retracting from about three feet away from the heart.
    In the Hanson Robotic system, the doctor uses a motion controller with a flexible guide catheter directly responsive to an operator's touch that replicates an operator's natural hand movements. The Hanson system is portable and attaches to a procedure table.

   REMOTE MAGNETIC NAVIGATION
    The Stereotaxis mouse and click system uses two large magnets that are incorporated into the EP laboratory. It requires a dedicated EP lab and space commitment. After making an ablation, there is about a 5-7 second delay before the operator can move on to another spot.

     The doctor interface screen displays fluoroscopy, intracardiac electrograms, and the EAM system. The magnetic vector can be manipulated from the mapping system or fluoroscopy screen.



    The Stereotaxis system has reported an excellent safety record. The lower contact forces may reduce pressure-related complications, such as steam pops and perforations. The Hanson system also is equipped with a limited force-sensing technology.
    "Automated schemes work reasonably well in the smooth surface of the left atrium but are less reliable in more trabeculated surfaces."²³⁴ Anecdotally the author has heard that doctors with access to the Stereotaxis system often work manually instead, because it is faster and less exasperating than the 5-7 second delay.
    The Hanson robotic system still requires extensive manual skill, while the Stereotaxis system is automated. Even with skilled, experienced operators it is still possible with a robotic system to have misplaced ablation burns or accidents such as perforations. Whereas the magnetic system using a mouse to make the ablations may be safer, and also more capable of being used by new operators.
    Should a patient seek out centers with these remote technologies? Probably not. In this author's opinion, these remote systems will not survive if they can not incorporate the advances in catheter development described above.

THE WATCHMAN DEVICE
    In this author's opinion, the most important recent innovation for patients is the Watchman Device. The theory behind the Watchman Device is most A-Fib clots originate in the Left Atrial Appendage (LAA). The Watchman Device closes off the LAA where 90-95% of A-fib strokes come from. It's a very low risk procedure that takes only a short time to install. Then you would usually not need to be on blood thinners.
    Here's how it works:
Once a patient's Left Atrial Appendage is measured, a wide-sheathed catheter with a spline is used to insert the Watchman device which has a self-expanding Nitinol (a special metal) open-ended circular frame. The atrial surface of this frame is covered with a thin, permeable 160 μm (micron) pore filter made of polyester material (Polyethylene Terephthalate known as Dacron or PET). This filter allows blood to pass through while stopping clots. Little hooks or anchors called fixation barbs at the middle of the device make sure it is attached firmly to the LAA wall. The Watchman device comes in multiple sizes from 21mm to 33mm to accommodate the different sizes of LAAs.
     Before the catheter is removed (which fixes the Watchman device in place), contrast agents are used to make sure the Watchman device is stable and entirely closes off the LAA opening. Over time heart tissue grows over the polyester (PET) material so that it completely closes off the LAA with smooth heart tissue similar to other heart surfaces. In this Occlusion slide, heart tissue has completely covered the Watchman device after only nine months.
    Some doctors are inserting the Watchman device in as little as 20 minutes. It is a low risk procedure with no surgery or ablation involved.
    Patients on Coumadin continue to take it for six weeks after the Watchman device is inserted. They are then examined using a TEE (Transesophageal Echocardiogram) to make sure there is complete closure of the LAA. At that time they are taken off of Coumadin.

    You can see a video of how the Watchman device is deployed at http://www.atritech.net/media/deviceanimation.aspx

    Coumadin reduces but does not totally eliminate the risk of stroke. Even with the proper INR levels of Coumadin, a small number of people with A-Fib have had strokes. The Watchman device also reduces but does not totally eliminate the risk of stroke. Like Coumadin, the Watchman is not an absolute guarantee one will never have a stroke. It basically reduces the risk of stroke similar to that of a person with a normal heart.
    Those of us who hate having to take Coumadin or blood thinners will be able to go in for a very low risk procedure that takes as little as 20 minutes, and replace Coumadin and blood thinners with the Watchman. This is incredibly good news for many of us.
    Even while we are waiting for or trying to decide on having a Pulmonary Vein Ablation, we can have the Watchman inserted and reduce our risk of stroke similar to that of a person with a normal heart.
    The Watchman device may become part of most catheter ablation procedures. If the catheter ablation procedure were unsuccessful or in case of silent A-Fib attacks after ablation, we patients would still be protected from an A-Fib stroke by the closing off of the Left Atrial Appendage. The Watchman Device or similar devices will probably become standard therapy not just for people with A-Fib, but also for anyone at risk of a stroke.
    Though still in clinical trials, the Watchman Device is available for most people. For a list of US doctors installing the Watchman Device, go to Doctors Installing the Watchman Device.

    56. "Are there different types of "Pulmonary Vein Ablation"? Are they different than "Pulmonary Vein Isolation?"
    Pulmonary Vein Ablation of A-Fib is a relatively new procedure whose techniques and language are evolving. What follows is perhaps an oversimplified, somewhat biased attempt at explaining the catheter ablation procedures in use today from a patient’s perspective. (Pulmonary Vein Ablation differs from other types of Catheter Ablation used in treating A-Fib, such as Ablation of the AV Node.)
   FOCAL CATHETER ABLATION or FOCAL POINT CATHETER ABLATION
    In this early procedure doctors mapped the sources of ectopic beats (beats that come from any region of the heart that ordinarily should not produce heart beat signals), then used a Radiofrequency (RF) catheter to “ablate” or burn off areas or points within the heart producing these ectopic beats. But if you weren’t in A-Fib at the time, it was difficult to identify the Focal Points or areas of the heart producing ectopic beats.
   SEGMENTAL ABLATION
    Doctors discovered that when a patient was not in A-Fib, the Focal Points producing A-Fib signals could still be found by identifying and mapping electrical potentials coming from these points. 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 can be measured and pinpointed, even if you aren’t in A-Fib. When the area is ablated, the potential disappears. Like taking the battery out of your car, removing this potential eliminates your A-Fib. (Doctors today do not usually ablate within the Pulmonary Veins because of the risk of causing Stenosis (swelling). Instead they determine where the A-Fib signal(s) exits the Pulmonary Vein opening and ablate there to "Isolate" the A-Fib signal.)
    CIRCUMFERENTIAL ABLATION (also called EMPIRICAL ABLATION) (In 2007 this is generally referred to as CIRCUMFERENTIAL PULMONARY VEIN ABLATION [CPVA]. The term "Empirical Ablation" is not currently in use.)
    A circular catheter is used to make Circular Radiofrequency Ablation lines around each of the four Pulmonary Vein openings (ostia) in the left atrium of the heart. This procedure isolates the Pulmonary Veins from the rest of the heart and prevents any A-Fib signals from these veins from getting into the rest of the heart.
   ANATOMICALLY BASED CIRCUMFERENTIAL PV ABLATION (In 2007 this is generally referred to as WIDE AREA CIRCUMFERENTIAL ABLATION [WACA])
    In this ablation procedure an RF catheter is used to make not always continuous ablation lines that encircle the Pulmonary Veins, thereby isolating them from the rest of the heart. This procedure originated in Italy. It has a good success rate with very few side effects both for Paroxysmal and for Chronic A-Fib.⁴⁰
    LEFT ATRIAL CATHETER ABLATION (In 2007 this term has generally fallen out of use.) Similar to Anatomically Based Circumferential PV Ablation. In both procedures instead of trying to make continuous, perfect linear lesions which can be difficult and time consuming, doctors use a "drop and drag" technique which leaves gaps that are usually closed over time with scar tissue.
    PULMONARY VEIN ANTRUM ISOLATION [PVAI]
    Instead on encircling each of the four Pulmonary Vein openings, one large encircling set of lesions isolates both the upper and lower left vein openings, another the upper and lower right vein openings. The encircling lesions are very wide and are in the Antrum rather than near the vein openings.
    SEGMENTAL ABLATION, CIRCUMFERENTIAL ABLATION, ANATOMICALLY BASED CIRCUMFERENTIAL PV ABLATION, LEFT ATRIAL CATHETER ABLATION. and PULMONARY VEIN ANTRUM ISOLATION are now generally referred to as types of PULMONARY VEIN ABLATION (PVA) or PULMONARY VEIN ISOLATION (PVI)). They are all similar in their approach. Their primary emphasis is the ablation/isolation of the Pulmonary Vein openings.
    Newer types of ablation have somewhat different ablation targets:
COMPLEX FRACTIONATED ATRIAL ELECTROGRAMS [CFAE]
AUTONOMIC GANGLIONATED PLEXI [AGP]
     The French Bordeaux group uses the term "electrical disconnection" rather than "Isolation" which very aptly describes what Segmental Ablation does.
    Another term that needs re-defining is “Pulmonary Vein Potentials,” because not all Potentials come from the Pulmonary Vein openings. "Pulmonary Vein Isolation" isn't accurate for the same reason.

    Which of the above procedures is the best? They all have similar success rates. Though the jury is still out on this, in this author's opinion patients do better with Segmental Ablation. Circumferential Ablation is quicker and faster for doctors and requires less mapping, but it’s difficult to make good circular ablations. The Pulmonary Vein openings aren’t always smooth, easily ablatable surfaces. Any gap in the circular ablation may result in more A-Fib. And not all A-Fib comes from the Pulmonary Veins. From a patient's perspective, you're better off with a doctor who will carefully map your heart to find out where exactly your A-Fib signals are coming from, and who will check for both Entrance and Exit Block (Isolation).
    Also, with Circumferential Ablation there might be a greater danger of Stenosis, a swelling of the Pulmonary Vein openings after ablation. PV Stenosis restricts blood flow into the heart and can lead to fatigue, flu-like symptoms and pneumonia. To quote Dr. Pierre Jaïs of the Bordeaux group in a debate at the NASPE convention in San Diego, “Why use a cannon to shoot an ant?”³¹ Segmental ablates only areas that have potentials, not the whole pulmonary vein opening(s).
    It is even more difficult to make continuous linear ablation lines around the Pulmonary Vein openings because the inside of the heart is not a continuously smooth surface.
    The LEFT ATRIAL CATHETER ABLATION procedure is faster, easier, requires less operator's skill, and is more cost effective for doctors. It will probably become the procedure of choice for most A-Fib medical centers. But from a patient's perspective it involves a lot of scarring of the heart by high wattage catheters. And 20% of patients have atrial flutter after the procedure because of all the gaps in the lesion lines, though most of this flutter eventually disappears as these gaps fill in with scar tissue.
    (As of January, 2010, many use the term "Catheter Ablation" of A-Fib to include all of the above different ablation techniques.)

    57. "I’ve heard of ablation catheters that use Cryo (freezing). Are they any good or better than the RF (Radio Frequency) catheters in use today for PVA(I) ablations? What about other energy sources like Microwave, Laser, High Intensity Focused Ultrasound (HIFU)?" (The FDA approved the first cryoablation balloon catheter for A-Fib December 20, 2010.)

    Currently the FDA has approved only RF and Cryo for A-Fib ablations. Microwave uses electromagnetic radiation to produce heat for tissue ablation. HIFU uses focused ultrasound (acoustic energy) to heat tissue. At the present time there doesn't seem to be much research interest in either of these energy sources.
    Laser energy, however, is a different story. Laser uses light energy to create ablation lesions. The Laser balloon catheter is one of the most exciting developments in catheter ablation. See the Laser Balloon Catheter. The laser seems to produce good lesions without the vaporizing and charring of tissue as with RF. An added advantage is direct visualization (endoscopic catheter). The doctor sees directly through the catheter the area he/she is ablating. However, the Laser Balloon Catheter is probably years away from FDA approval.
    That currently leaves the Balloon catheter field to Cryo which uses very cold temperatures to freeze tissue to create lesions without the vaporization, charring, and tissue damage of RF. Many centers around the US are starting to use the FDA approved CryoBalloon Catheter.

According to a pioneer in the technique, Dr. Walter Kerwin of Cedars-Sinai-Los Angeles, Cryo ablation seems to have definite advantages over RF.¹⁰¹ (Dr. Kerwin performed the first catheter Cryo ablation in the Western United States in 2005.)

ADVANTAGES OF CRYO ABLATION:

- Cryo ablation allows a doctor to test an ablation before making it permanent. Heart tissue can be slightly frozen to test whether it is responsible for producing A-Fib signals. That tissue can then be re-warmed and restored to its normal electrical function. Heat-based therapies like RF don’t allow that---once the heart tissue is burned, it stays burned.

- With Cryo there is less risk of damaging other areas of the heart or esophagus. Often in catheter ablation doctors have to work close to critical structures such as the heart’s pacemaking system, the esophagus, or the coronary arteries. For example, an RF ablation in the wrong spot can block the normal electrical conduction in the heart and require the surgical insertion of a permanent pacemaker. With Cryo ablation (which freezes tissue instead of ablating it), the risk of damage to critical structures in minimized.

- Cryo minimizes the risk of perforation. Because Cryo preserves heart tissue integrity rather than burning it, there is minimal risk of perforation. For example, a Cryo catheter is less likely to perforate the atrial wall.

- With Cryo there is little or no discomfort or pain during the procedure. Like putting a cold pack on a pulled muscle, the freezing acts as a natural anesthetic.

- With Cryo there is less risk of Stenosis (swelling ). An RF ablation in the Pulmonary Vein openings can sometimes result in Stenosis (swelling or narrowing of the Pulmonary Vein opening) which restricts or blocks blood flow. Since Cryo does not burn and instead preserves heart tissue integrity, there is less risk of Stenosis.

- When cold temperatures are applied, Cryo catheters stick to the heart tissue they touch, much like a tongue on cold metal. Since the heart is beating and in constant motion during an ablation, this is a significant advantage over RF. The ability of the Cryo catheter to stick to the exact spot to be ablated, helps the doctor avoid any accidental slips of the catheter tip, thereby preventing damage to nearby critical structures.

- Cryo produces no crust formations. RF burns can cause a crust to form over the ablated area (called a "thrombus"). This crust can fall off and lodge in a blood vessel, perhaps causing a blood clot and stroke. (That’s one of the reasons blood thinners like heparin are used during RF ablations, to prevent these blood clots.) With Cryo ablation, this risk of thrombus is minimized.

DISADVANTAGES OF CRYO ABLATION:

- Currently Cryo ablations using standard Cryo catheters take longer to do than RF. But Cryo ablations using the new balloon catheter will reduce the procedure time. FDA clinical trials of the CryoCath balloon catheter are underway in twenty A-Fib medical centers in the US (the Arctic Front -TM balloon CryoAblation catheter made by Medtronic, Inc.).

ADDED JULY 7, 2008
    Ablating using the CryoCath balloon catheter seems to be faster and easier, as well as safer than RF. Here is a recent study reported in the A-FibNews section:
June 28, 2008 "Cryoablation (with the CryoCath Arctic Front cryoballoon): Safer than RF..." Dr. Burghard Schumacher of Germany described a study involving 346 patients with Paroxysmal (293) or Persistent (53) A-Fib. Following one Cryoballoon ablation, 74% of Paroxysmal patients were free of A-Fib and in permanent sinus rhythm. But this figure was much lower for those with persistent A-Fib---just 38%. There were no strokes, no pulmonary vein stenosis, no esophageal injury, and no coronary artery injury as sometimes occurs with RF ablation (RF ablations typically have a major complication rate of around 4%). The main complication reported was a temporary palsy of the phrenic nerve. According to Dr. Philippe Ritter, president of Cardiostim, "Cryoablation (with the Cryoballoon catheter) appears to have a lower complication rate than RF ablation and is easier to perform...but we need some more years to look at it and compare it with RF ablation." (See: http://www.theheart.org/article/877315.do)
    (Editor's Comments: A 74% cure rate for the CryoCath balloon catheter is similar to current cure rates for RF ablations for Paroxysmal A-Fib. The low 38% cure rate for Persistent A-Fib might be due to only having one ablation. Most RF ablation procedures for Persistent A-Fib now require two or more ablations. [See: 95% Success Rate in Curing Persistent A-Fib.] Also, in this study only the Pulmonary Vein openings were treated with the CryoCath balloon catheter. They did not attempt any other lines or lesions as is commonly done with current RF ablations for Persistent A-Fib. Persistent A-Fib is more complex and difficult to cure. As doctors get more experienced with Cryo, they may well be able to achieve similar success rates as RF for Persistent A-Fib.
    In the future we may see centers first use Cryoballoon catheters to isolate the Pulmonary Veins because it is safer, easier, and uses less fluoroscopic exposure; and secondly use RF or non-balloon Cryo catheters for linear lesions and to target other areas of the heart in more complex cases of Persistent A-Fib. Cryo will probably also be used to ablate near the esophagus to prevent Atrial-Esophageal Fistula [see Morady: Boston A-Fib Symposium 2008].
    Cryoballoon catheter ablation may also be the answer to the problem of re-do's. [See Dr. Marchlinski's presentation on Ablation re-do's.] All too often RF ablation patients have to return for a second ablation, because of re-growth and reconduction of the RF ablated areas, and because PV isolation with RF is difficult to achieve in a uniform fashion, even with experienced operators. Circumferential ablation with small-tipped catheters often results in gaps in the lesions lines and uneven scar formation. The Cryo balloon catheter ablation may solve the problem of re-do's, because of its ability to easily and quickly produce uniform pulmonary vein isolation. [See: Dr. Kerwin's explanation of Cryo Ablation.])
    The Cryo balloon catheter may become a major improvement in the treatment of A-Fib. It has already been approved in Europe, with close to 100% success rate in isolating the PVs, and 75-80% success in keeping patients free of A-Fib without anti-arrhythmic drugs.

added December 31, 2009
    Doctors have been doing RF ablations for years. They work. The Cryo Balloon and RF catheter ablations are pretty much equally effective. The Cryo Balloon is safer, but not that much safer than RF which is a low risk procedure.
    If we had a choice between the Cryo Balloon and RF, we'd probably choose the Cryo Balloon. But an RF ablation remains a good option with a high success rate and low complication rate. (Thanks to Jean Kirkland for suggesting this update.)

    58. "How dangerous is a Pulmonary Vein Ablation procedure? What are my risks? What are my chances of dying from a PVA procedure?"
    Pulmonary Vein Catheter Ablation is considered a "low-risk procedure."³³ In practice, for most A-Fib patients, the actual risks are so small that it’s much safer getting a PVA than not getting one. A PVA is much safer than a life on antiarrhythmic drugs or in A-Fib (See Catheter Ablation vs. Drugs.)
    But what are the actual risks involved?
    1. When the catheters are inserted, there is a "small risk"³³ of damaging the veins and/or arteries which could cause bleeding (Arteriovenous [AV] Fistula). This can be repaired surgically. It’s similar to, though obviously not the same as, the risk you take when you donate blood.
    Your groin will generally have two access site points, one on each side. After a Pulmonary Vein Ablation, some minor bruising is common at each site with minor soreness as if you had banged the area. Bruising may occasionally be seen to extend down the leg. This is normal as is an occasional small quarter sized bump in the area. (If larger swelling or more significant pain occurs at the area, please contact the electrophysiologist who did the procedure.)

    2. To get to the left atrium which is usually the source of most A-Fib signals, the doctor must pass the catheter through the transseptal wall between the left and right atria. This puncture technique and the catheter manipulation involved increase the chance of heart puncture and bleeding (tamponade) through the heart walls. If this happens, blood may fill the sac surrounding the heart (the pericardium) and may have to be drawn off with a needle and catheter (Pericardiocentesis). Very rarely, surgery may be required. The more experienced and skillful your doctor is, the less this catheter manipulation is a risk.
    (Note: The doctors don't just punch through the transseptal wall. The catheter is often inserted through a membrane formed when your heart developed as a fetus. In early fetal development your two atria weren’t completely separate. As the transseptal wall formed, this opening between the two atria (the foramen ovale) closed up. The catheter is inserted through this former opening or membrane. After the ablation procedure, this membrane closes back up and heals over.)
        (In some adults like Tedy Bruschi, former linebacker of the New England Patriots, this foramen ovale opening between the two atria doesn't grow closed. This allows small blood clots that otherwise would be absorbed in the lungs to pass from one atrium to the other, and then travel to the brain. It's estimated that nearly 20% of adults have a foramen ovale opening between the two atria that never closes up completely.)

    3. As in A-Fib, there is a risk of blood clotting and stroke, which is why most medical centers use a blood thinner like Heparin during the procedure to prevent clotting during the application of RF energy to heart tissue. Also, before an ablation procedure a patient is often checked to see if there is any pooling or clotting of blood in the atria. If any clots are found, medications can be used to dissolve them. According to figures from the French Bordeaux group, "the risk for thromboembolic (stroke) events is lower than 0.5%."³⁴

    4. When the pulmonary vein openings are ablated or isolated, there is a risk of damaging and narrowing these vein openings. If a significant amount of this swelling (Stenosis) occurs, the doctors may have to stretch the narrowed area or insert a stent to keep the veins open. This ability to correct Stenosis correspondingly lessens your risk.
    (Note: In the early days of Pulmonary Vein Ablations, Stenosis (defined as over 50% narrowing of the vein opening) was a major problem. But with more experience and the use of irrigated-tip low wattage catheters, it is less of a problem. Ask the doctor or medical center you are working with how often Stenosis occurs due to their ablation procedures and how severe it generally is. If they can't provide those figures, think about going somewhere else. You will find that most major medical centers now have fairly low risks of Stenosis.)

    5. A possible risk to consider is the amount of X-ray exposure during an ablation procedure. Most catheter ablation procedures use fluroscopy, a type of X-ray with a fluorescent screen, to see inside the heart and to position the catheter(s). Many medical centers have limits to how much fluroscopy you can be exposed to and will stop a procedure if you exceed it. (Written May, 2010. Many centers are now using non-fluroscopy type imaging such as MRI which greatly reduces the amount of X-ray exposure.)
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    6. Then there is the unforeseen, the strange things that happen sometimes in operations---allergic reactions to medications, anesthesia problems (some centers put you under completely, others don't, "extremely small risk of infection, valve damage, or heart attack"³³ during the procedure. But the doctors and staff are prepared to deal with emergencies and complications and they monitor you very closely.
    There is very little risk of dying from a Pulmonary Vein Ablation (Isolation) procedure. "To the best of our knowledge, no deaths have been reported in the literature in more than 2000 PV isolation procedures."³⁴ Recently, however, there have been 20+ deaths reported due to a very rare complication called "atrial-esophageal fistula" where a hole forms between the atrium and the esophagus. This may be due to using high wattage catheters in the back of the atrium near the esophagus.⁶³ If you develop unexplained fevers exceeding 100 degrees anytime within the first 3 weeks post-ablation, you need to contact the electrophysiologist who performed your procedure ASAP. Low grade fevers of around 99 degrees are common in the first day or so post-ablation.
    Another rare complication is damage to the Phrenic nerve in the Pericardium around the heart due to heat from the ablation catheter. This may result in breathing difficulties.⁹⁵
    An even more rare complication is getting the loop/mapping catheter caught in the mitral valve. In some cases it may require open heart surgery to remove it. The more experienced and skillful your doctor is, the less likely this is to happen. (When talking with a potential ablation doctor, you may want to ask how often does the doctor's patients have to be taken for open heart surgery.)
    After an Pulmonary Vein Ablation you may have some minor chest pain for the next week or so. The pain will often worsen with a deep breath or when leaning forward. This is pericardial chest pain from the ablation and is generally not of concern. It should resolve within a week although it might increase for a day or so after the ablation.

    Since Pulmonary Vein Ablation is a relatively new procedure, we don't have much data yet on long term risks. One long term study of Pulmonary Vein Ablations (Isolations) has indicated that many of the bad remodeling effects of A-Fib such as enlargement of the left atrium and the ability of the atria to contract can be reversed after a successful PVA(I).⁵⁸    For a more detailed examination of this question, see Wilber.

    59. "What is Atrial-Esophageal Fistula? I heard it can kill you. How can it be prevented during an ablation?"
    Atrial-Esophageal Fistula (a fistula is an abnormal duct or passage) is a very rare complication (1/1000+ cases) that, unlike most other risks of catheter ablation, often results in death. The esophagus lies next to the back of the left atrium. When heat is applied to the back of the heart during an RF ablation burn, that heat can be transmitted to the esophagus resulting in thermal injury, and in a worst case scenario, necrotic (death of cells) or ulcer-like changes. Over 2-3 weeks this can develop into inflammation (mediastinitis) and a fistula connection between the esophagus and the left atrium. In one small study of 28 patients where no preventive measures to prevent Fistula were used, 47% of patients had thermal injury and 18% (5 of the 28) demonstrated necrotic or ulcer-like changes in the esophagus.²⁵⁴
    Most doctors and medical centers now take measures to prevent Atrial-Esophageal Fistula. But because this complication is so rare, it's hard to determine which preventive measures are the most effective. (if you are considering a catheter ablation, you need to ask your doctor what measure(s) they take to prevent Atrial-Esophageal Fistula.)
    Here are some of the preventive measures in use today with a discussion of their effectiveness and limitations:
    1. Minimizing power at the posterior wall when ablating. But we don't know what the amount of power is that would minimize damage. Even applying 10 Watts can heat up the esophagus, because the posterior wall of the left atrium can be very thin in spots, and the esophagus can be found right next to the posterior wall of the left atrium. One study recommends limiting RF energy to under 20 Watts for less than 15-20 seconds when ablating in a region next to the esophagus.²⁵⁴
    2. Temperature monitoring with a probe that is positioned in the esophagus. Using temperature monitors does reduce damage to the esophagus. See Dr. Reddy Preventing Atrial-Esophageal Fistula.
    But the type of temperature probe is very important. A temperature probe with a surrounding plastic sheath (like a stethoscope) can take 40 seconds to show a significant temperature rise. If you strip away the plastic cover, the temperature goes up in only a few seconds.
    In a typical ablation when the medical staff sees a temperature rise, they stop the ablation. But the temperature will continue to rise. After a 30 second ablation, it may take an additional 80 seconds for the temperature to come back down. Is this temperature rise causing damage to the esophagus? Temperature monitoring isn't perfect.
    Where the temperature probe is located will change the readings. In animal studies they inserted a balloon with many temperature probes into an esophagus. If the temperature probe was on the side where one was ablating, the rise in temperature was almost immediate. But if it was on the other side, there was a slow rise; and when the ablation was stopped, the temperature continued to rise before eventually falling.
    In a small study from Brazil an catheter with a temperature probe was placed in the esophagus and moved side to side depending on where the heart ablation catheter was positioned. This system produced no ulceration. See Dr. Reddy Strategies to Prevent Atrial-Esophageal Fistula.
    3. Imaging and locating the esophagus. A strategy such as using Barium Paste in the esophagus can be used to see where the esophagus is during an ablation. The Barium will show up on a fluoroscopy (X-Ray) image. The doctor can then avoid ablating near the esophagus or use low power in ablation areas next to the esophagus.
    4. Moving the esophagus. The esophagus can move spontaneously during an ablation. Can it be moved manually away from where a catheter is ablating? Using barium paste to identify the location of the esophagus, an experimental system using a soft plastic tube with a stylet (a slender medical probe) was used to move the esophagus. But prospective randomized studies need to be done to determine if this system actually protects the esophagus. Can moving the esophagus cause other problems?
    (Editor's Note: Moving the esophagus (combined with temperature monitoring) seems like an amazingly simple, practical method of avoiding damage to the esophagus. In fact, one of the vendor booths at the 2011 Boston A-Fib Symposium demonstrated such a system that was trying to get FDA approval.)
    5. Force monitoring. Force applied seems to make a difference, whether or not one uses temperature monitoring. See Contact Force Sensor Catheter.
    6. Conscious Sedation vs. General Anesthesia. Dr. Reddy described studies by Dr. Natale in which 48% of patients under General Anesthesia (completely unconscious) had esophagus ulceration versus only 4% of patients under Conscious Sedation. See Dr. Reddy Strategies to Prevent Atrial-Esophageal Fistula. (But most centers today now use General Anesthesia rather than Conscious Sedation, because they believe better overall ablation results can be achieved.)
    7. Protecting the Esophagus. Experimental studies have been done in which a cooling balloon was positioned in the esophagus to protect it from heat from the ablation catheter. This decreased the chance of ulcer formation in the esophagus. But the cold might attenuate lesion formation by the RF catheter.
    8. Cryo Ablation. Small studies have indicated that Cryo (Freezing) Focal Ablation at regions near the esophagus is safe. Cryo "can cause transmural injury to the esophagus but may be less likely to result in deep ulceration and fistula formation."²⁵⁴However, this strategy involves removing an RF Catheter and inserting a Cryo Catheter which lengthens and complicates the ablation procedure. Hospital administrators and insurance companies may not approve of this strategy because of the added costs. Most centers today are not set up to use Cryo Catheters during an RF ablation.
    9. Proton Pump Inhibitors and Ulcer Inhibitors. Most centers now put patients on Proton Pump Inhibitors like Nexium, Prilosec, Prevacid, etc. for 2-3 weeks after an ablation. Even if there is ulceration in the esophagus from the heat of an ablation catheter, the Proton Pump Inhibitors prevent gastric acids from backing up into the esophagus in case of Gastroparesis (weak stomach not emptying its contents) or GERD (Gastroesophageal Reflux Disease). Atrial-Esophageal Fistula usually occur 2-3 weeks after an ablation. It takes that long for gastric acids to burn through the esophagus areas structurally weakened by catheter heat from inside the heart.
    Some centers also treat patients for 2-3 week after an ablation with sucrafate (Carrafate), a medicine used to heal ulcers.
    See also Preventing Atrial-Esophageal Fistula.

WHAT'S THE BEST STRATEGY?
In this patient's opinion, when asking doctors what strategies they use to prevent Atrial-Esophageal Fistula, the most practical, easy-to-implement strategies are:
    Minimizing Power at the Posterior Wall
    Using Temperature Monitoring
    Imaging and Locating the Esophagus
     Proton Pump Inhibitors
    Administering Proton Pump Inhibitors for 2-3 weeks after an A-Fib ablation is probably the most effective, the most likely strategy to prevent Atrial-Esophageal Fistula, and the strategy easiest to implement. Depending on their doctor's recommendation, anyone having an A-Fib ablation should consider taking prescription or over-the-counter Proton Pump Inhibitors for 2-3 weeks after an ablation.

CAVEAT
    If you develop unexplained fevers exceeding 100 degrees anytime within the first 3 weeks after an ablation, you need to contact the electrophysiologist who performed your procedure ASAP. You may have an Atrial-Esophageal Fistula. (Low grade fevers of around 99 degrees are common in the first day or so post-ablation.)

    60. "During the ablation procedure A-Fib doctors actually burn within the heart with RF energy. How does this burning and scarring affect how the heart functions? Should athletes, for example, be concerned that their heart won't function as well after an ablation?"
    Particularly during ablations for persistent (Chronic) A-Fib, long procedures and extensive ablation are often required. These result in significant scarring and damage to heart tissue. But a study from the French Bordeaux group found "recovery of atrial contractile function" (the heart goes back to beating and contracting normally) in 98% of patients in sinus rhythm after six months of follow-up.²¹⁴
    In general, the less ablation and heart scarring, the better. But it's encouraging that from this preliminary study, even after extensive ablations, the heart usually returns to normal.

    61. "I know I need a Pulmonary Vein Ablation (Isolation) procedure to stop my A-Fib. A-Fib destroys my life. I can't work or exercise, and live in fear of the next attack. And antiarrhythmic meds cause me bad side effects.
    But I'm worried about being exposed to radiation during the ablation. How dangerous is the radiation (fluoroscopy) during an ablation?" (Thanks to Stephanie Fagan for this question.)
    Exposure to radioactivity during an ablation used to be a legitimate concern. (Doctors and nurses wore lead aprons during an ablation.) Back in 2003, a typical A-Fib ablation resulted in around 50 minutes of fluoroscopy time.¹⁷²One hour of fluoroscopy imaging is associated with a lifetime three-in-ten thousand chance (0.03%) of developing a fatal malignancy, and a risk of passing on a genetic defect of 20 per 1 million births.¹⁷⁵ These risks were considered relatively small compared to the risks of being in A-Fib, antiarrhythmic drug therapy, and surgery.¹⁷⁴Doctors follow directives which limit the amount of radiation you can be exposed to during an ablation. If you get close to exceeding these limits, they will stop the ablation (though this rarely happens). But many centers today use much less or no fluoroscopy at all. Instead many use 3D non-fluoroscopy (no radiation) imaging techniques such as Intracardiac Echocardiography (ICE), and Magnetic Resonant Imaging (MRI). You need to check with your A-Fib center as to how much radiation their typical A-Fib ablation patient is exposed to. The radiation dose for a typical A-Fib ablation is estimated to be 18.4 mSv.¹⁷⁵However, the radiation amount at your A-Fib center will vary depending on what type of imaging equipment they use.
    Once you learn what amount of ablation radiation you might be exposed to at your A-Fib center, then you can compare it to the following to determine if you should be concerned:
    • Average Background Radiation/year                    2.4 mSv
    • Chest X-Ray Radiation                                        0.02-0.2 mSv
    • Full-mouth Dental X-Ray                                      0.03-0.2 mSv
    • Mammogram                                                      0.7 mSv
    • Spinal X-Ray Radiation                                        1.5 mSv
    • Heart CT Scan Radiation (100-600 Chest X-rays)    12 mSv
    • 25.5 min. fluoroscopy during an A-Fib Ablation      15.2 mSv¹⁷⁶

    But bear in mind that, even a one hour-long exposure to fluoroscopy, is a relatively small risk compared to the risks of being in A-Fib, antiarrhythmic meds, and/or surgery.
    (The author did a very unscientific survey of the A-Fib medical centers in his area. The average seemed to be 10-20 minutes of fluoroscopy time [for those who used fluoroscopy] for an A-Fib ablation, but more complicated cases could expose patients to 60(+) minutes of fluoroscopy time.)

Protecting Yourself From Radiation Damage
    You can take measures before and after your ablation to help protect yourself from radiation damage. Since much of the cancer-causing damage from ionizing radiation is from hydroxyl free radicals, it's recommended to take antioxidant supplements to neutralize them. A typical plan is to take the following natural supplements every six hours for at least 24 hours before and after your radiation exposure. These are available without a prescription from health food stores. But check with your doctor before taking any supplements.
    1. Vitamin C 1000 mg
    2. Lipoic Acid 400 mg
    3. N-Acetyl Cysteine 200 mg
    4. Melatonin 3 mg

Added 8/28/2010
    "Radioactivity in low doses is good for us."
    In 1983 180 apartment building were built in Taiwan. But somehow highly radioactive Cobalt-60 was mixed into the concrete. The 10,000 people who lived in these apartments for 9-20 years received an average of 74 millesieverts (mSv) of radiation a year (a typical catheter ablation using fluoroscopy produces around 15 mSv¹⁷⁶---non-x-ray imaging systems much less).
    But cancer rates of people living in these highly radioactive buildings were 3.6% of prevailing Taiwanese rates. This is a reduction in cancer rates of 96.4%. This phenomena is perhaps explained by the theory of hormesis which holds that intermediate levels of radioactivity actually stimulate life and improve health.
http://www.jpands.org/vol9no1/chen.pdf
http://www.ecolo.org/documents_in_english/taiwan-cobalt-60-apartment-04.htm
    (Author's Note: The nuclear theory that any level of radiation is cumulatively damaging may not be valid [the "Linear No Threshold (LNT)" theory.] The levels of radiation received during a typical catheter ablation may not be dangerous, but may even be healthful.)

    62. "I have serious heart problems and chronic heart disease along with Atrial Fibrillation. Would a Pulmonary Vein Ablation help me? Should I get one?"
    This is a judgment call only you and your doctor can make. A PVA(PVI) may help you. But your time and efforts might be better spent getting your other heart problems under control. As compared to other heart problems, episodes of A-Fib feel weird and uncomfortable but are normally not life threatening.

    63. "I have an enlarged heart due to years of A-Fib. I was told I can't have a Pulmonary Vein Ablation (Isolation) procedure. Why is that?"
    A-Fib is a progressive disease that, among other bad effects, tends to enlarge and stretch your left atrium. Because your left atrium is fibrillating or quivering rather than beating properly, it isn't filling and emptying properly. Your left atrium has to work harder than normal and tends to stretch and dilate over time.
    (An enlarged heart may also proceed or cause A-Fib. High blood pressure or other heart problems may enlarge your heart and lead to or trigger A-Fib.)
    A normal left atrium measures around 2.0-4.0 cm. Some centers won't do a Pulmonary Vein Ablation (Isolation) procedure if the left atrium is over 5.5 cm. Because the left atrium heart walls have been stretched thin in an enlarged heart, it is easier to puncture them when doing a left atrium ablation. Surgeons also are reluctant to operate on someone with an enlarged heart. (Some people, like Lance Armstrong and other athletes, have a naturally larger heart due to their levels of physical activity. The above rules would not apply to them.)
    However, some centers do perform PVA(I)s on patients with an enlarged heart. Newer ablation techniques are less likely to puncture heart walls. (The author does not currently have a list of centers doing ablations on patients with an enlarged heart. But if you email me, I will try to find someone near you: afibfriend@verizon.net.}
    If you have A-Fib, you should have your left atrium measured to see if it is being enlarged.
    One of the benefits of a successful PVA(I) (besides curing A-Fib) is that it often reduces an enlarged left atrium.⁴⁰

    64. "I am 82 years old. Am I too old to have a successful Pulmonary Vein Ablation? What doctors or medical centers perform PVAs on patients my age?"
    I don't know if there is an age limit to having a successful PVA and what that age limit might be. A formal or informal survey needs to be done of the major A-Fib centers to answer these questions. I've heard of a successful PVA on someone 92 years old. (This is a very important question since so many people in their 80s are getting A-Fib.)
    Ultimately it's a question only you and your doctor can answer based on your individual needs, health, medical history, how your A-Fib affects you, etc.
    I don't know of any doctors or medical centers who specialize in patients over 80 years old who need PVAs. Unfortunately I have heard of some centers who have a policy of not taking patients over 80 years old.

    65. "I've had a successful Pulmonary Vein Ablation (Isolation) procedure a year ago. I'm in normal sinus rhythm and have been A-Fib symptom free. Will my A-Fib eventually return over time, or am I permanently cured? Someone told me A-Fib is a progressive disease that is incurable and will eventually come back." (Thanks to Clark for asking parts of this question and to A-Fib Support Volunteer Jerry for helping write this answer.)

A-FIB IS CURABLE
    A-Fib is a progressive disease, but it is curable. When you isolate the Pulmonary Veins and other areas of the heart which produce A-Fib signals, those areas are "cured." They won't produce A-Fib signals again unless some gap develops in the isolating lesions.
    We're not really sure what causes A-Fib to develop in the first place. But we do know that it usually occurs in the openings of the Pulmonary Veins which are similar genetically to the Sinus Node and usually beat in sync with it. When you isolate the Pulmonary Vein openings, you're removing most of the sources of A-Fib signals. Does that mean you can't develop A-Fib in some other part of your heart? No, that can happen in theory. But that doesn't mean it will or must eventually happen. You're much less likely to get A-Fib in other parts of the heart than in the Pulmonary Veins.

IS A PVI PERMANENT?
    We can't answer definitively yet whether a successful Pulmonary Vein Isolation (Ablation) PVI(A) is permanent. PVI(A)s are relatively new. (The author had his PVI(A) in 1998 when he was 57 years old, and was A-Fib free for 12 years. However, back in 1998 only one of his Pulmonary Veins was isolated. He did have a brief A-Fib attack in August, 2010 which has not re-occurred. His doctor is reluctant to put him on any medications and is taking a wait-and-see approach.)
    There is a tendency for ablated heart tissue to heal itself, regrow the ablated area, reconnect, and start producing A-Fib signals again. (See Third and Fourth PV Isolation/Ablation Procedures.) But if this happens, it usually occurs within approximately the first six months of the initial PVA(I) (but see the recent January, 2010 research mentioned below.).

REGROWTH/RECONNECTION
    Recent research (January, 2010) indicates that for a small number of people, a successful Pulmonary Vein Ablation (Isolation) procedure may not be a permanent "cure." Dr. Francis Marchlinski of the Un. of Pennsylvania persuaded patients who had experienced successful PV ablations and who were A-Fib symptom free, to be re-examined in the EP lab. He found that some had Regrowth/Reconnection in their ablated vein openings even though they were A-Fib symptom free. He also examined patients who had Regrowth/Reconnection and reoccurrence of A-Fib after a successful PV ablation.
    He estimated that there is a 5-6% chance of Regrowth/Reconnection each year, out to five years. He doesn't have data for beyond five years.

RECURRENCE DUE TO HEART HEALTH FACTORS
    At the Boston A-Fib Symposium 2011, Dr. David Wilber of Loyola, Chicago cited several studies which also found approximately a 7% yearly rate of late recurrence. But he suggested the causes may not be only PV reconnection, but also heart health factors such as hypertension, diabetes, large left atrium, obesity, smoking, etc.
    He pointed out that atrial deterioration and heart disease may progress even if a patient is in sinus rhythm due to factors such as atrial remodeling and fibrosis.
    (Author’s Note: People in sinus rhythm certainly have improved heart health and quality of life than when they were in A-Fib. But being in sinus rhythm doesn’t mean one can ignore other health and heart factors.
    It was recommended that patients A-Fib free after a catheter ablation be counseled and monitored closely for heart health factors, particularly high blood pressure. They should be warned about the possibility that their A-Fib could return if they don't take care of their overall heart health.)

WORST CASE SCENARIO NOT ALL THAT BAD
Let's discuss a worst case scenario for you. A year from now you develop A-Fib again, because of a gap or a regrowth/healing of one of your original ablation lesions or you develop a new area of the heart which produces A-Fib signals. It's a piece of cake to fix that gap or to find that extra source (compared to the work an EP had to do on your original ablation). Instead of the usually 3-5 hour ablation, the EP may only need 20 minutes to fix one or two areas. It's a safer, easier procedure both for you and your EP.

The bottom line for you is: you're not likely to develop A-Fib again.

And even if you do, it's much easier to fix with a second ablation which usually would be safer and faster than your first ablation.

O.R. REPORTS
    If you want more specific information about your ablation procedure, ask your doctor or his office for your O.R. (Operating Room) report. (It's very technical. You can email or send me a copy if you want help reading it [Feedback]. See the Operating Room Report question.)

    66. "I just had Pulmonary Vein Ablation (Isolation) (PVA) procedure, but I still don't feel quite right? How long does it take before I know the procedure was a success? Also, I've got bruising on my leg, my chest hurts, and I have a fever at night. Is this normal?" (Thanks to Marva Harp for this question.)
    Some people feel great and are in perfect sinus rhythm after a PVA(I) procedure. But for most of us it usually takes two or three months for the ablation scars to heal and for our heart to learn to beat normally again. Doctors sometimes help this process by prescribing antiarrhythmic meds for a month or longer. You may also have to continue to take Coumadin for a while.
    Right after the PVA(I) you may experience the following:
    1. Your groin will generally have two access site points, one on each side. After a Pulmonary Vein Ablation, some minor bruising is common at each site with minor soreness as if you had banged the area. Bruising may occasionally be seen to extend down the leg. This is normal, as is an occasional small quarter sized bump in the area. (If larger swelling or more significant pain occurs at the area, please contact the electrophysiologist who did the procedure.) One of the reasons for this bruising is the heavy dose of blood thinners you were administered during your ablation procedure to prevent a possible stroke.
    2. After an Pulmonary Vein Ablation you may have some minor chest pain for the next week or so. The pain will often worsen with a deep breath or when leaning forward. This is pericardial chest pain from the ablation and is generally not of concern. It should resolve within a week, although it might increase for a day or so after the ablation. (The author speculates that this chest pain may be due to the heat from the catheter ablation burns which may temporarily irritate the Pericardium, the sac around the heart.)
    3. Low grade fevers of around 99 degrees are common in the first day or so post-ablation. (If you develop unexplained fevers exceeding 100 degrees anytime within the first 3 weeks post-ablation, you need to contact the electrophysiologist who performed your procedure.)

    67. "Where can I get more information on what was done to my heart during my Pulmonary Vein Ablation?"
    Ask your doctor or his office for your O.R. (Operating Room) report. This is a technical, detailed, step-by-step account of what the doctors found in your heart and what was done. Because it is technical and hard to understand, it isn't normally given to patients unless they ask for it. (If you need help understanding it, email or send me a copy [Feedback]. Together we can probably figure it out.)
    "Do I have a legal right to my own medical records? Do they belong to me?"
    Medical records are the property of the medical provider. They do not belong to the patient. You have a right to view the originals, and to obtain copies under Health and Safety Code sections 123100-123149.5. The information belongs to the patient, but the physical pieces of paper, X-rays, etc. belong to the hospital or medical provider. See http://www.lnctips.com/whoownsmedicalrecords.
    Hospitals and other health organizations have a duty to protect the confidentiality of medical records - because the patient owns the information contained on those pieces of paper, not the organization. (There are some exclusions to this mandate, such as reporting of public health risks, child abuse, etc.). The organization can't divulge this confidential information to others without the patient's consent, a court order, or a subpoena.

    68."I've had a successful Pulmonary Vein Ablation to cure my A-Fib. Do I still need to be on blood thinners like Coumadin or aspirin?"
    If you don't have any symptoms, you probably are A-Fib free and have less chance of getting A-Fib again than most other people. However, though "cured" of your A-Fib, you may still be experiencing silent A-Fib (A-Fib with no symptoms) which can be dangerous, according to studies presented at the 2006 Boston A-Fib Symposium (See Kottkamp and Calkins).
    Since Pulmonary Vein Ablation of A-Fib is a relatively new procedure, we don't have enough historical perspective and case studies yet to answer definitively whether or not you need to continue taking anticoagulants. This is a judgment call for you and your doctor. However, your chances of getting an A-Fib stroke are practically eliminated if your heart is in normal sinus rhythm. But even people who don't have A-Fib can get a stroke. Currently there is no medication or treatment that would absolutely guarantee one would never get a stroke, even for people in normal sinus rhythm.
    (Added 9/4/10) A study in 2010 indicates that anticoagulants can be stopped 3-6 months after a successful PVA(I) Anticoagulants (Coumadin) can be stopped 3-6 months after a successful Pulmonary Vein Ablation (Isolation)
    Taking a low dosage anticoagulant like a baby aspirin (81 mg) every day isn't likely to harm you and is actually recommended for overall heart health and stroke prevention.²⁹

    Jay S asks, "Which is preferred to prevent the possibility of a stroke in the event my A-Fib re-occurs---a baby aspirin dosage of 81 mg or a 325 mg?"
    After a successful Pulmonary Vein Ablation (Isolation), doctors usually keep you on Coumadin for three to six months while your heart heals. Re-growth or re-occurrence is less likely to occur after six months and doesn't occur often enough to justify keeping "cured" A-Fib-ers on Coumadin.
    For people with normal sinus heart rhythm, doctors sometimes suggest taking a baby aspirin (81mg) once or twice a day. A baby aspirin twice a day may give you as much help as a 325 mg tablet once a day with a lessened risk of stomach upset and ulcers. But realize that two baby aspirins or a 325 mg aspirin a day will not guarantee that you will never have a stroke.
    (The enteric coating on baby aspirin may prevent its effective absorption. However, it’s hard to find non-enteric coated baby aspirin. What some people do is chew the baby aspirin to get rid of the enteric coating.)
    The author does not know the answer to Jay S's question as to which is better---baby aspirin 81 mg or 325 mg. He invites anyone with insights to write him at afibfriend (at) verizon.net (the "@" is written as "at" to prevent access from automated spam).

    69. "I just had a Pulmonary Vein Ablation. But my A-Fib feels worse and is more frequent than before the ablation, though I do seem to be improving each week. My doctor said I shouldn't worry, that this is normal. But I feel terrible. Is my ablation a failure?"
       You won't know if your ablation is a success for about three months. It takes that long for your heart to heal.
    There is a period of time (which varies from patient to patient) when the A-Fib may seem to get worse. This happens in some people because of the inflammation and trauma to the heart and body tissues caused by the catheter ablation burns and the poking around in your heart during the procedure. These can seem to exacerbate your A-Fib. (An ablation procedure doesn't create new A-Fib producing areas in your heart, though it may stir up existing A-Fib areas temporarily.)
    Another reason you may still have A-Fib is because of gaps in the ablation lines. In the most common A-Fib ablation procedures used today, doctors try to create ablation lines around your pulmonary vein openings to isolate them from the rest of your heart. (A-Fib producing areas are usually found inside your pulmonary vein openings.) But it's difficult making continuous, perfect ablation lines. Sometimes there are gaps in those lines which let A-Fib signals through. But as your heart heals, these gaps usually fill in gradually with scar tissue that reaches its thickest size at the end of three months.

    Remember, also, that it isn't the end of the world if your ablation isn't a total success. Some 15-20% of ablations are not successful. These patients have to go back for a second ablation (including myself). This second ablation is usually, though not always, easier than the first. Often all the doctor has to do is ablate any gaps that haven't filled in or ablate where there has been re-growth/re-connection. See Second Ablations.
    In general, if you're in sinus rhythm after the third month, the chances are good you'll stay in sinus rhythm. If you're in sinus rhythm after the sixth month, the chances of a reoccurrence of A-Fib are even less.
    However, reoccurrence of A-Fib does happen. Many people (as many as 15%-25%) have to go in for a touch up ablation procedure. This usually isn't the doctor's fault. Heart tissue is very tough. There is a tendency for ablated heart tissue to heal itself, re-grow the ablated area, reconnect, and start producing A-Fib signals again. (See Third and Fourth PV Isolation/Ablation Procedures.) (See the question, "Am I permanently cured?"

    70. "I am having a Pulmonary Vein Ablation next week for my A-Fib. Because i love to exercise, I am very curious as to what and how much physical activity I can participate in after the procedure. Everything i read says 'You can resume normal activity in a few days.' But i know that what is "normal" is not normal for me. Is there a range of BPM (beats per minute) to keep my heart within? Light walking? Exercising/light weights in the gym? Is there a common road to recovery for those of us who are very physically active?" (Thanks to Monique Van Zeebroeck for this question.)
    Caution would say to start off slow, then work your way up. You could get a Polar (or other) heart rate monitor to keep track of your heart rate. Your heart is considered healed from the scarring of the ablation after three months (possibly sooner).
    Often you feel so good being in sinus rhythm after an ablation, that you can't wait to exercise, to do something physical. But even though you feel great, it's better to be prudent and rein yourself in for a short while.
    (A special thanks to Ed Webb, a very active exerciser, who shares his following experiences and insights.)

It seems the prevailing opinions seem to lean toward resuming normal activities a week to two weeks after the procedure. In fact that's what my EP had recommended for me (the first time around). I started light walking and cycling, but unrelated to these activities I also was doing some outside work on my boat (during the fall here in Florida where it can be putrid). On two separate occasions--I happened to be wearing a heart rate monitor--my heart was a comfortable 85 BPM and then WHAM back into A-Fib! As I am one of those persistent A-Fibbers, I had to be cardioverted both times. This all happened within a span of 3 weeks after the procedure. Needless to say, I was somewhat discouraged thinking the ablation had been a failure. My EP wasn't too concerned and just advised me to hang in there. After the second cardioversion, I finally got the hint and took it really easy for the next month, after which I started a walking regimen where I allowed my heart rate to increase from 80BPM on the first day up to 100BPM at an increase of 1 beat per day. Once I hit the magic 100, I got back on the bike and picked it up from there and was fine after that (until 2 years later when I had another onset!). The bottom line is I think this all had to do with not allowing enough time for the scar tissue to heal.

My second time around (which was 2 years ago) I pretty much stuck to the same routine. First two weeks, absolutely nothing. Then easy walks allowing my heart rate to increase a little each day. I walked for a month (starting at 80 and finishing at 105). After 6 weeks or so, I was back on the bike and doing maximum efforts by the end of 3 months. I have been in sinus rhythm ever since (that sound you hear is me knocking on my desk!)

Anyway, I hope this gives you at least one perspective for your recovery. All the best for your procedure.

    71. "I know I'm overweight. Doctors list me as "morbidly obese." But my heart starts racing whenever i try to exercise, because of my A-Fib. What can i do? Should I get a Pulmonary Vein Ablation (PVA)?"
    EPs (Electrophysiologists) may be reluctant to do a PVA in your case. Today's imaging systems have difficulty seeing through significant fat mass to get a clear picture of the heart.
    An EP may refer you to a surgeon for a Mini-Maze operation which is done under general anesthesia and is considered more traumatic, invasive, and risky than a PVA and, like a PVA, isn't a guaranteed success. (See Pros and Cons of a Mini-Maze Operation.) But it may be your best option. (Make sure you discuss with the surgeon the risks of general anesthesia for someone overweight. Your heart may have a hard time beating properly under general anesthesia with the extra weight around it.)
    The author also struggles with a weight problem, as most of us do, and doesn't have any good advice for losing weight. But if you could find a way to lose some of your weight, then you'd have the option of getting a PVA to fix your A-Fib.

72. "I had been in A-Fib for a number of years. I know A-Fib remodeled my heart. My left atrium is enlarged and I probably have developed a lot of fibrosis. But I've just had a successful A-Fib ablation and feel great. Will my left atrium, ejection fraction, fibrosis, etc. improve?" (Thanks to Mark for this question.)
    Pulmonary Vein Ablation (Isolation) [PVA(I)] is a relatively new procedure. We don't have a lot of data on its long term effects.
    Obviously your atria function much better after a successful PVA(I). Your atria pump more blood into your ventricles like a normal heart. Any electrical remodeling effects of A-Fib have probably been reversed. One long term study indicates that many of the bad remodeling effects of A-Fib such as enlargement of the left atrium and the ability of the atria to contract can be reversed after a successful catheter ablation.⁵⁸
    In an analysis of 17 different studies enrolling 869 patients, a successful catheter ablation significantly decreased (improved) left atrial diameter and volume, but had no significant difference in ejection fraction and actual emptying fraction.²⁵⁸ (If before an ablation one's ejection fraction is low, one would expect an improvement over time as the heart becomes stronger. But for someone with a normal ejection fraction before ablation, there may not be much of an improvement. "Ejection Fraction" just measures what the ventricle does with the blood it receives, not whether it receives more or less blood from the left atrium.)
    A Bordeaux group study using Pulmonary Vein Isolation and Linear Lesions with an average follow-up of eleven months showed that left atrial volumes fell, but also that left atrial contractual and filling function almost returned to normal for Paroxysmal patients. For Chronic patients, left atrial contraction was low after ablation, but after eleven months it improved considerably. The study also showed improvements in ventricular, diastolic and systolic function. This improvement occurred even if patients had reoccurrences of A-Fib. (Boston A-Fib Symposium 2006 Dr. Wilber).
    In another study from the Bordeaux group, A-Fib patients with Congestive Heart Failure and an ejection fraction of less than 45% (normal ejection fraction range is 56%-78%), had a PVA(I). After approximately 12 months, 78% were A-Fib free without meds. They had significant improvement in left ventricular function including increases in ejection fraction of approximately 21% (as well as exercise capacity, symptoms, and quality of life). The ejection fraction also improved significantly (24%) in the control group of A-Fib patients without Congestive Heart Failure.²⁵⁹
    (It's not all that surprising that A-Fib patients with a low ejection fraction would improve after a successful PVA(I). But the control group without Congestive Heart Failure also improved their ejection fractions. In this study a successful PVA(I) improves ejection fraction even if one has a relatively normal ejection fraction to begin with.)
    One A-Fib remodeling effect that will probably not improve is fibrosis. Fibrosis is most likely irreversible. See Structural Remodeling in A-Fib.

73. " I’ve had two catheter ablations. But they were failures. I don’t feel much better than I did before the ablations. Should I get a third ablation or go for surgery? How many ablations/surgeries are too many?"
It’s not uncommon to have a third (or even a fourth) Pulmonary Vein Ablation (PVA). But after two ablations (or after one surgery and one ablation), you should consider going to one of the few Electrophysiologists (EPs) who specialize in Chronic (persistent) or difficult A-Fib cases. They have developed step-by-step methods of tracking down and ablating difficult to find A-Fib generating spots in the heart and have years of experience in handling difficult cases. But their results are not guaranteed, especially in cases such as yours.

MEASURE YOUR TRANSPORT FUNCTION (HOW WELL YOUR LEFT ATRIUM PUMPS)
    Before considering a third ablation, you should have your transport function measured and documented. For safety’s sake and for your own peace of mind, you may want to have a full electrophysiology study done of your heart. This would hopefully show how the scaring from your previous ablations/surgery has affected your heart. You may also want to obtain your O.R. (Operating Room) reports of your previous ablations/surgery. These would normally show what the doctors found in your heart and what ablations were performed.
    What’s important is not the number of ablations you’ve had, but what was actually done in your heart.
    Armed with this knowledge, you then need to discuss with the doctor who would be performing your third ablation, "What steps will you take to make sure my left atrium pumping function is not compromised?"

TOO MANY ABLATIONS/SURGERY
You should be concerned about having too many ablations/surgery. Excessive scarring of the left atrium can render it electrically inert or "dead" (asystolic). Transport function, the ability of the left atrium to pump, may be compromised or destroyed. It’s possible during a difficult ablation or during the more extensive surgical operations to ablate or scar extensively in the left atrium in hopes of ablating or isolating all the A-Fib generating spots. But this approach can permanently damage the ability of the left atrium to pump. The author is aware of cases where, after only two ablations/surgeries, a patient’s left atrium was so scarred that it no longer functioned properly, though the patient was still in A-Fib. In one case the A-Fib trigger was found in the right atrium.
If your left atrium is rendered electrically inert or "dead," you are more at risk of a stroke than people in A-Fib. You must forever be on blood thinners like Coumadin or Pradaxa, and these won't guarantee that you won't have a stroke.

OTHER OPTIONS
Another option you should consider is Ablation of the AV Node and Insertion of a Pacemaker. Though this is generally an option of last resort, it may be better for you than the risk of losing the ability of your left atrium to pump (transport function).

    Current Mini-Maze surgical approaches probably have less chance of being an effective option in your case. They currently can’t reach all the areas of the heart where A-Fib signals can originate. (Mini-Maze surgeries currently can not be re-done or touched-up by a second Mini-Maze surgery, because of the previous scarring.²⁶⁸ But a catheter ablation may be used after a failed Mini-Maze to try to find more elusive A-Fib spots in the heart. Though success is not guaranteed.)

    The Cox Maze operation (Radial Maze) has a high success rate. But if you have a left atrium larger than 6.0 cm or if you've been in A-Fib for over five years, the long term success of the "Cut and Sew" Maze operation is under 80%.²³⁷   This under 80% success rate would probably apply to difficult cases like yours where two ablations didn’t work.
    The typical Cox Maze is a one-size-fits-all operation that involves extensive scarring of the heart and sometimes results in reduced atrial function. You should be concerned that the extensive scarring of the Cox maze operation added to your previous scarring, may damage your heart's functioning. If you're considering having a Cox Maze operation, ask the surgeon before the surgery if they can tell how much scarring has occurred in your heart and how the Maze surgery will affect your transport function.
    If I were you, I'd ask for as much of a guarantee as possible that the Surgeon's or EP's additional lesions would not harm my heart's functioning.

(In the future [this was written in May, 2011] the Hybrid and Convergent Ablation procedures may become an option. These are new, somewhat experimental surgeries being developed in which a surgeon and a EP work on the same patient sequentially. A surgeon operates, then hours or even months later a catheter ablation doctor (EP) completes the treatment. But currently it’s too early to tell if these Hybrid or Convergent procedures will be effective in difficult or Chronic (persistent) A-Fib cases. [The author has heard of one center where both the surgeon and the EP work on a patient at the same time. The surgeon makes lesion lines on the outside of the heart, while simultaneously the EP inside the heart uses a mapping catheter to measure the effectiveness of the surgeon’s lesions. The advantage of this system is the EP can tell the surgeon immediately if their lesions are effective or not before the surgeon completes the surgery. After the surgeon is finished, the EP maps and ablates any other A-Fib signals within the heart]}

BOTTOM LINE
It’s very discouraging to have had two failed ablations (I had five before being cured). But don’t give up. You know you can be fixed. It’s just a question of finding the right doctor and treatment option for you.

Chronic (persistent) A-Fib questions.

    74 "I have Chronic Atrial Fibrillation (the heart remains in A-Fib all the time). Am I a candidate for a Pulmonary Vein Ablation? Will it cure me? What are my chances of being cured compared to someone with Paroxysmal (occasional) A-Fib?"
    This is a question that is currently in dispute among researchers in A-Fib.³⁴ However, most clinical studies suggest that Paroxysmal is more frequently curable by PVA(PVI) than Chronic. In fact, the French Bordeaux medical group, considered among the world's leaders in A-Fib research, now uses a combination focal and linear catheter ablation procedure for Chronic A-Fib as compared to a focal ablation procedure for Paroxysmal A-Fib.³⁴ They only consider patients with chronic A-Fib if they have "symptomatic and complicated AF" because of the following reasons: patients with Chronic A-Fib often have "poor hemodynamic tolerance" (their blood isn't being pumped out properly), "suspicion of tachycardiomyopathy" (the heart tissue may have been damaged by the rapid, irregular heart beats or fibrillation), and "suspicion of thromboembolic events" (a greater risk of stroke).³⁴ Linear ablation techniques, though more difficult to perform effectively, may work better for people with chronic A-Fib and/or structural heart disease.³⁵ In a Boston A-Fib Symposium 2006 presentation Dr. Jaïs from the French Bordeaux group reported a study in which 95% of Chronic A-Fib patients were restored to normal sinus rhythm (See Jaïs).
    For someone with Chronic A-Fib, you have a better chance of being cured of your A-Fib if you've been Chronic for a short period of time rather than for a number of years. Does that mean that people with Chronic A-Fib have little hope of being permanently cured by a catheter ablation? No. It's just that right now most heart centers have a long waiting list and have better success rates with Paroxysmal A-Fib.

    75. What causes Paroxysmal (occasional) A-Fib to turn into Persistent (Chronic) A-Fib?
    Researchers are still working to find the answer(s) to this question. The main trigger seems to be increased pressures in the left atrium that causes the muscle fibers around the pulmonary vein openings to start beating on their own. Uncontrolled blood pressure, untreated sleep apnea, or a worsening cardiomyopathy seem to be key factors that make people progress from Paroxysmal to Persistent A-Fib. (Thanks to Dr. Sidney Peykar for these observations.)
    Even after a successful ablation for Persistent A-Fib, "the long term success rates depend mostly on treatment of hypertension and obstructive sleep apnea."

    76. "I'm eighty years old and have been in Chronic (persistent/permanent) A-Fib for 3 years. I actually feel somewhat better now than when I had occasional (Paroxysmal) A-Fib. Is it worth trying to get an ablation to cure my Chronic A-Fib?"
    With Chronic A-Fib of long duration, perhaps not. Although a few centers get very good results when treating Chronic A-Fib even of long duration (the French Bordeaux group achieves an acceptable success rate after 2 ablations), most centers have a success rate of only around 50% for Chronic A-Fib. And although catheter ablation is a low risk procedure, there are still risks.
    Many centers won't ablate patients who are over 80 years old or in Chronic A-Fib for over a year. There is a higher risk of complications in older people, and it is more difficult to ablate Chronic A-Fib. (In Chronic A-Fib there are often multiple spots in the heart producing A-Fib signals. It's hard to identify and ablate [isolate] them all.)

The Positive Side of being in Chronic A-Fib
    Sometimes people feel relieved to be in permanent A-Fib. There's no longer the fear, uncertainty, and shock of an A-Fib attack. You can adjust your lifestyle to how your heart behaves, because it doesn't change much. You may be short of breath, somewhat light headed, tired, and unable to work or exercise hard. But you get used to it. You may even feel better than when you had Paroxysmal A-Fib. In addition, an ablation may be only partially successful and have the unwanted consequence of putting you back into Paroxysmal A-Fib.
    You still need to take blood thinners to prevent an A-Fib stroke. But if you get the Watchman device installed (very low risk), it closes off your Left Atrial Appendage where 95% of A-Fib clots originate. You can then go off of Coumadin.

The Negative Side of being in Chronic A-Fib
    The down side of being in Chronic A-Fib is your heart forever and always will not pump properly. Blood flow to your brain and other organs is reduced by about 15%-30%.^{132,
164,
165} This can lead to conditions like dementia and Alzheimer's.98^{,
163, 76}(If you are a superior athlete like a bicyclist or runner, your exercise may overcome this reduced blood flow.)
    A-Fib is a progressive disease. It tends to get worse even in Chronic A-Fib. Your atria expand and stretch. Your ejection fraction diminishes. Chronic A-Fib produces fibrosis and collagen deposits which stiffen the heart and make it less flexible. All this leads to conditions such as Congestive Heart Failure, Cardiomyopathy¹⁶¹, heart weakness, heart attacks, etc.^{77,
61, 167}But please weigh the above statements carefully (the author is concerned that they may create unwarranted fear). How do you feel? If you don't feel any symptoms and your doctor says your heart isn't enlarging and/or developing poor ejection fraction, etc., then there's no need to rush out to get a Pulmonary Vein Ablation which does involve real risk.

The Bottom Line
    You can be cured of Chronic A-Fib, even at your age. But it will take at least 2 ablations. And it won't be easy finding a doctor to do it. (There is a short list of doctors at specialists in persistent/chronic a-fIB. You need someone with a proven track record in ablating Chronic A-Fib.) However, an ablation is more risky at your age.
    On the other hand, you can live in Chronic A-Fib. Many people do. The key to living a satisfying life in Chronic A-Fib may be good rate control. For example, a resting heart rate of around 80 beats per minute with an exercise rate of 110 is very close to that of a normal person. People with good rate control of their Chronic A-Fib report a good quality of life and seem less prone to develop other heart or mental problems.
    Are you happy or content with your quality of life in Chronic A-Fib? If so, then the added hassles and risks of an ablation are probably not worth it for you. Only you (and your doctor) can decide if it's better to spend your twilight years in a perhaps reduced but satisfactory quality of life.

    77. "I am in Chronic (all-the-time) A-Fib. I feel tired and a little light-headed, probably because my atria aren't pumping properly. Is there any way I can improve my circulation, without having to undergo a Catheter Ablation (poor success rate and risky at my age) or Surgery (even more risky)?"
    In theory, yes.
    In Chronic A-Fib it's not unusual to feel tired and light-headed. Your atria are fibrillating instead of pumping blood into the ventricles. Blood flow to your brain and other organs is reduced by about 15%-30%.^{132,
164,
165}
    But your ventricles still function by suctioning blood from the atria much like a turkey baster sucks up liquid. You can improve to some extent the strength and capacity of your ventricles by exercise, such as by walking on a treadmill or at the Mall.
    You can also improve the oxygen saturation of your blood by using an Oxygen Concentrator ($500-$1,000). While on a treadmill, for example, you can breath in concentrated oxygen through a cannula, a flexible tube you insert into your nostrils. You can measure how much oxygen is in your blood by using an pulse oximeter ($50). The desired range is 95-100% oxygen saturation. (Some athletes with good circulation use this technique to improve their athletic performance.)
    However, the author is unaware of any studies demonstrating the effectiveness of the above techniques for Chronic A-Fib patients. (An interesting research study would be to examine Chronic A-Fib patients before and after an exercise program and/or concentrated oxygen to see if there is any real change in their circulation or if they feel better.)

Disclaimer: the authors of this Web site are not medical doctors and are not affiliated with any medical school or organization. The information on this site is not intended nor implied to be a substitute for professional medical advice. Always seek the advice of your physician or other qualified health professional prior to starting any new treatment or with any questions you may have regarding a medical condition. Nothing contained in this service is intended to be for medical diagnosis or treatment.

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(This page last updated 1/03/11)