Atrial Fibrillation

Atrial Fibrillation
RESOURCES FOR PATIENTS

FAQs

"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?"
"I have a lot of stress at work. Does this stress cause or trigger my A-Fib?"
"Can I exercise if I have Atrial Fibrillation? Should I exercise? Should I cool my sex life?"
"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."
"What is the best A-Fib treatment option for me?" (You may need to read the complete Cures section of A-Fib.com to familiarize yourself with the various treatment options, if you haven't done so already.)
"Can I die from my Atrial Fibrillation?"
"Which medications are best to control my Atrial Fibrillation?"
"I take atenolol, a beta-blocker. Will it stop my A-Fib."
"Which is the better anticoagulant to prevent stroke---warfarin (Coumadin) or aspirin? What's the difference between warfarin and Coumadin?"
"Is the "Pill-In-The-Pocket" treatment a cure for A-Fib? When should it be used?"
"Is Atrial Fibrillation a prelude to a heart attack?"
"My doctor says I have Atrial Fibrillation. Could it be something else? Should I get a second opinion?"
"Are there exercises that will help eliminate my Atrial Fibrillation?"
"Is my Atrial Fibrillation genetic? Will my children get A-Fib too?"
"Why do older people get Atrial Fibrillation more than younger people?"
"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?"
"Will my A-Fib go away on its own?"
"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?"
"How dangerous is a Pulmonary Vein Ablation? What are my risks?"
"I have 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?"
"I have serious heart problems and chronic heart disease along with Atrial Fibrillation. Would a Pulmonary Vein Ablation help me? Should I get one?"
"What caused my A-Fib?"
"Can I drive my car if I have 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?"
"Is Atrial Fibrillation curable? Or can you only treat or control it?"
"I have occasional (Paroxysmal) A-Fib. I've heard that A-Fib is a progressive disease that only gets worse. What are my chances of getting permanent (Chronic) A-Fib?"
"Is there a diet I could follow which would cure my A-Fib?"
"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?"
"Why does so much Atrial Fibrillation come from the Pulmonary Vein openings?"
"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?"
"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?"
"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?"
"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?"
"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?"
"How can I tell when I'm in A-Fib or just having something like indigestion?"
"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?"
"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 chronic A-Fib. In case of an emergency, should I carry a wallet card or a medical bracelet? What information should I put on it?"
"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 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?"

    "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.
    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.)
"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.
"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.
"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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"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.
"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 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.)
"Which is the best A-Fib treatment option for me?"
This is a decision only you and your doctor can make. But, depending on the type of A-Fib you have, here are some guidelines which may help you. Listed below are A-Fib conditions as described by people with A-Fib. Click on the kind of A-Fib you have in order to read your possible options.
1. "My A-Fib just started."
2. "My A-Fib is occasional (Paroxysmal) with no symptoms (sometimes referred to as "silent' A-Fib)."
3. "I have infrequent, short episodes of symptomatic A-Fib."
4. "I have Paroxysmal (occasional) A-Fib but am in good health overall."
5. "I have Paroxysmal (occasional) A-Fib but also have serious heart and/or other health problems."
6. "My A-Fib is Persistent or Chronic (all-the-time)."
7. "I have A-Fib but am allergic to Coumadin, Heparin, Lovenox and most blood thinners."
8. "I've had two failed left atrium ablations and have tried many different medications."
1. "My A-Fib just started." You might be helped by a Electrical Cardioversion and/or Chemical Cardioversion. Doctors can perhaps shock your heart back to beating normally. Antiarrhythmic meds may also be used for several months to train your heart to stay in normal sinus rhythm. Ideally after this treatment, your heart won't go back into A-Fib. But don't delay. This treatment seems to work best in cases of recent onset A-Fib.
2. "I have occasional (Paroxysmal) A-Fib with no symptoms (sometimes referred to as "silent' A-Fib)." Doctors may have discovered you had A-Fib during a routine examination, but you weren't aware of anything wrong and feel generally OK.
      Since you've probably had A-Fib for a while, an Electrical Cardioversion may not have as good a chance of getting you back into normal sinus rhythm. But it might be worth trying.
      Another option might be to just live with the A-Fib, since it doesn't seem to affect you very much. You still need to talk with your doctor about whether or not you should be on blood thinners, since with "silent" A-Fib you are at risk of an A-Fib stroke. Your doctor may also prescribe Rate Control medications to make sure your heart doesn't beat too fast.
      However, this option of just living with A-Fib may eventually cause you problems. Over time A-Fib tends to stretch and weaken the heart often leading to other heart problems and heart failure.⁷⁷ An enlarged atrium (approximately over 55 mm) may limit your options. Some centers won't accept patients for a PVA(I) procedure if they have an enlarged heart, because the heart walls have been stretched thin and are easily perforated and burnt through by an RF ablation catheter. Also, A-Fib over time may lead to decreased mental abilities and even dementia, because blood isn't being pumped properly to the brain and other organs (see A-FIB DECREASES MENTAL ABILITIES).
      If you choose this option, it is important to monitor you closely; for example, your atria should be measured periodically to see if they are being stretched and enlarged, and your cognitive abilities should be tracked over time. But you may be able to live for years with occasional "silent" A-Fib episodes which don't progress to anything worse.
      The use of antiarrhythmic medications with their risk of bad side effects may not be justified when your A-Fib is "silent" and infrequent. The same holds for a Pulmonary Vein Ablation (Isolation) procedure. (Many doctors won't perform a PVA(I) on someone relatively A-Fib symptom free.)
3. "I have infrequent, short episodes of symptomatic A-Fib."
      An Electrical Cardioversion might be worth trying, though it generally has the best chance of success with early onset A-Fib.
      The option of just learning to live with your A-Fib may not be acceptable to you, depending on how bad your A-Fib symptoms are. Not only do you have to deal with the A-Fib symptoms, but also with the psychological trauma and fear of knowing an A-Fib attack is always possible.
      Since your A-Fib episodes are relatively infrequent, antiarrhythmic meds may keep your heart in normal sinus rhythm. But watch for bad side effects. There is a fine line between giving your body time to adjust to the antiarrhythmic med, and recognizing that the medication is causing you unacceptable side effects. Some people have had success with flecainide (brand name Tambocor) or the newer meds dofetilide (Tikosyn) and Rhythmol SR.
      Because your symptoms are infrequent, you may have a simpler, more easily fixed type of A-Fib; i.e., your A-Fib may come from only one or two spots in the heart which a Pulmonary Vein Ablation (Isolation) has a good chance of curing. However, many doctors and medical centers are hesitant to perform a PVA(I) on someone with relatively infrequent A-Fib episodes.
4.     "I have Paroxysmal (occasional) A-Fib but am in good health overall."
      An Electrical Cardioversion may be effective for you, though it generally has the best chance of success with early onset A-Fib.
      Antiarrhythmic meds may help in the short term, but they tend to lose their effectiveness over time. In general, don't expect an antiarrhythmic med to be a permanent cure for your A-Fib.
      You have perhaps the best odds of being permanently cured by a Pulmonary Vein Ablation (Isolation) procedure. Doctors may use both Electrical Cardioversion and Chemical Cardioversion during and after a PVA(I) to help the heart stay in normal sinus rhythm.
5. "I have Paroxysmal (occasional) A-Fib but also have serious heart and/or other health problems."
      An Electrical Cardioversion may not be an option for you, depending on your other heart and/or health problems.
      The antiarrhythmic Class III drugs Sotatol, Dofetilide, and Azimilide appear to be safer to use if you have structural heart disease.¹² Amiodarone is also a Class III drug, but it often has more serious bad side effects even though it is probably the most effective antiarrhythmic med.
      A PVA(I) can be very effective; however, you need to prioritize and take care of your most serious heart and health problems first. A successful PVA(I) may improve your overall heart functions (see Left Atrial Function...After Catheter Ablation).
6. "I have Persistent or Chronic (all-the-time) A-Fib."
      People with Persistent or Chronic A-Fib often have more than one or two spots in the heart producing A-Fib signals. These A-Fib signal sources often have gotten stronger over time and are less likely to be affected by Electrical Cardioversion. Antiarrhythmic meds may also be less effective.
      Until recently your chances of being cured of Chronic A-Fib by a PVA(I) were less than if you had Paroxysmal (occasional) A-Fib. Doctors have to work harder to find and ablate the many A-Fib signal sources often found in Chronic A-Fib patients. Some centers have rules such as not accepting patients who have had Chronic A-Fib for over a year. However, a recent study by the French Bordeaux group reported a 95% success rate in curing Chronic A-Fib after two ablation procedures.⁹² (See also Strategies for Catheter Ablation of Long-Lasting Persistent Atrial Fibrillation.) If you have Chronic A-Fib, you have to be prepared to have at least two or possibly three ablation procedures.
      People with Chronic long-standing A-Fib were generally thought not to benefit from a Maze operation such as the Radial Maze. But recent developments in the Maze operation offer new hope to Chronic A-Fib-ers.⁹⁷ (See also Cox maze operation for patients with Chronic A-Fib.). The Mini-Maze operations probably aren't a satisfactory option if you have Chronic A-Fib, since they currently can't reach or block all areas of the heart where A-Fib signals are found.
7. "I have A-Fib but am allergic to Coumadin, Heparin, Lovenox and most blood thinners."
      You might be a good candidate for a Mini-Maze operation.
  PROS AND CONS OF THE MINI MAZE OPERATIONS
       Though not open heart surgery like the Radial Maze, the Mini Maze operations are nevertheless very traumatic for the body and require general anesthesia. (Think of three knives being stuck through your chest.) Your Pericardium is cut or punched open, your lungs have to be alternately deflated and inflated which can be difficult for older people whose lungs aren't very elastic, your Left Atrial appendage is cut out and/or stapled shut while the heart is still beating which can be technically challenging.
      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, the Mini Maze operation may work for you. But anything more complicated is something of a crap shoot.
      One big advantage of the Mini Maze operations is that the Left Atrial Appendage 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. (You may want to read in the PersonalExperiences section a description of THE SALTMAN MICROWAVE MINI MAZE OPERATION.)
      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. 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.
      (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 Radial Maze 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 forced to make a decision, this author would choose the Radial Maze over the Mini Maze operations. Even though the Radial Maze involves open heart surgery and is more traumatic, its success rate in curing A-Fib is better (97%), and it may have less adverse effects on the functioning of the heart. (see Advances in Surgical Therapy for A-Fib.)
8. "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 Radial Maze operation may work for you.
      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.
"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.)
"Which medications are best to control my Atrial Fibrillation?"
     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). See Medications.
"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.
"Which is the better anticoagulant to prevent stroke---warfarin (Coumadin) or aspirin? What's the difference between warfarin and Coumadin?"
    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) 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."
    Weighing the various risk/benefit ratios is a decision for you and your doctor and may change in life as you do.
    "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. Significantly above 3.0 you run the risk of having a hemorrhagic (bleeding) stroke. Below 2.0 you are more in danger of having an ischemic (clotting) stroke, the kind that most often occurs in A-Fib.
    It is often difficult to maintain this INR ratio, 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 ratio right. There are home use kits available for testing your own INR ratio.
    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.
    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
"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 example is to take 100 mg of flecainide up to three times at 20 minute intervals to stop or shorten an A-Fib episode (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. However, this approach doesn't seem to be commonly used.
    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.
"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.
"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.
"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.)
"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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"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.)
"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?"
    Not only does excess iron in the blood trigger or predispose you to A-Fib, 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 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.)
"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.
"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?"
A-Fib is a progressive condition. The longer you have it, in general the worse it gets. 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.
With today's current Pulmonary Vein Ablation (Isolation) procedures using Pulmonary Vein Potentials, 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 cured.) Your odds aren't going to get much better than that.
"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 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. This can be repaired surgically. It’s similar to, though obviously not the same as, the risk you take when you donate blood.
    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 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. 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 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, 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.
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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 "atrio-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 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
    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 atria 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.
"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.
"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.
"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.
"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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"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. 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.
"Is Atrial Fibrillation curable? Or can you only treat or control it?"
A-Fib is definitely curable. If you have A-Fib, no matter how long you've had it, your goal should be a complete and permanent cure. If your doctor is satisfied with keeping your A-Fib "under control," get a second opinion.
"I have occasional (Paroxysmal) A-Fib. I've heard that A-Fib is a progressive disease that only gets worse. What are my chances of getting permanent (Chronic) A-Fib?"
    A-Fib is a progressive disease, but you won't necessarily go into permanent (Chronic) A-Fib. In one study of patients with intermittent A-Fib, 8% went into permanent A-Fib in one year, 18% went into permanent A-Fib within four years.⁵⁷
    In A-Fib your heart has a tendency to remodel itself both physically and electrically. The atria tend to enlarge and develop thinner walls, and their ability to contract is diminished (called "ejection fraction"). The heart develops fibrosis. Electrically the A-Fib episodes tend to become longer and more frequent. "A-Fib begets A-Fib."
    But one long term study of Pulmonary Vein Ablations has indicated that many of these remodeling effects can be reversed.⁵⁸
"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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"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. 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 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 http://www.vagalafibinfo.fsnet.co.uk (This site seems to have disappeared from the Internet as of October, 2006).
    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.
"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.)
"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?"
    If you don't have any symptoms, you probably are cured of A-Fib 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.
    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
"I just had 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?" (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.
    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, regrow the ablated area, reconnect, and start producing A-Fib signals again. (See Third and Fourth PV Isolation/Ablation Procedures.) (See the following question, "Am I permanently cured?"
"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?"
    We can't answer definitively yet whether a successful PVA(I) is permanent. PVA(I)s are relatively new. (The author had his PVA(I) in 1998 when he was 57 years old, and hasn't had an A-Fib symptom since. However, at that time only one of his Pulmonary Veins was isolated. In theory the other veins could start producing A-Fib signals. But that hasn't happened.)
    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).
    However, when the PV is isolated and disconnected and hasn't reconnected, it seems to be permanent. Intuitively it makes sense that A-Fib wouldn't reoccur in areas that were successfully ablated and that haven't reconnected. But it's too early in the history of PVA(I)s to say this definitively.
"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.
   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 ISOLATIONare 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 term “Isolation” probably will not stand the test of time since it really is inaccurate as applied to Segmental Ablation. The Focal Points are ablated and destroyed rather than being “isolated” from the rest of the heart. The French Bordeaux group uses the term "electrical disconnection" 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.
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    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.
    Also, with Circumferential Ablation there is 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 recent 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.
    Another question for patients is whether it's better to ablate A-Fib generating areas in the heart, or leave them intact but block these areas from propagating A-Fib signals into the rest of the heart. Segmental ablates these A-Fib generating areas in the heart, while other procedures leave them intact but block them from the rest of the heart.
"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?"
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 rewarmed 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 somewhat 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 CryoCath Technologies, Inc.).

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.
"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 84 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.
"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.
"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.
"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 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.
    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.)
"I have chronic 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.)
"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 these extra beats cause you problems, beta blockers and antiarrhythmic meds used to treat A-Fib may help. 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.
"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?"
The gold standard of A-Fib monitors is called the Holter monitor. (Incomplete)

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