Atrial Fibrillation
 RESOURCES FOR PATIENTS

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REFERENCES
    ¹mayoclinic.org, "Atrial Fibrillation," "Other Treatment," 2001.
    ²mayoclinic.org, "Heart Rhythm Disorders: Arrhythmias," "Atrial Fibrillation," "Treatment Options," 2001.
    ³University of Pennsylvania, "Atrial Fibrillation Educational material," 2001, p. 2.
    ⁴mayoclinic.org, "Atrial Fibrillation," "Catheter Ablation," 2001.
    ⁵"Patients and physicians need to understand at the outset that atrial fibrillation is rarely eliminated." Wyndham C. "Atrial Fibrillation The Most Common Arrhythmia." Texas Heart Institute Journal, 2000;27,3, p. 261.
    ⁶Haines D. "Atrial Fibrillation: New Approaches in Management." Un. of Virginia multi-media presentation, 1999, p. 2.
    ⁷Haines D. "Atrial Fibrillation: New Approaches in Management." Un. of Virginia multi-media presentation, 1999, p.3.
    ⁸Cannom, D. "Atrial Fibrillation: Nonpharmacologic Approaches." American Journal of Cardiology 2000;85: p. 25D
    ⁹Haines D.,  "Atrial Fibrillation: New Approaches in Management." Un. of Virginia multi-media presentation, 1999, p. 4
    ¹⁰"...pharmacologic conversion is successful in 10 to 30 percent of cases," Falk R. "Atrial Fibrillation." New England Journal of Medicine, Vol. 344, No. 14; April 5, 2001, p. 1072.
    ¹¹Falk R. "Atrial Fibrillation." New England Journal of Medicine, Vol. 344, No. 14; April 5, 2001, p. 1071
    ¹²Haines D., "Atrial Fibrillation: New Approaches in Management." Un. of Virginia multi-media presentation, 1999, p. 4.
    ¹³Reiffel J., "Drug choices in the treatment of atrial fibrillation." American Journal of Cardiology May 2000;85, Issue 10, Supplement 1, p. 12.
    ¹⁴Haines, D. "Atrial Fibrillation: New Approaches in Management." Un. of Virginia multi-media presentation, 1999, p.2.
    ¹⁵Scheinman M. "Nonpharmacological Approaches to Atrial Fibrillation." Circulation. 2001;103:p. 2120
    ¹⁶"Atrial Fibrillation Educational Material" University of Pennsylvania. 2002, p. 3.
    ¹⁷Haïssaguerre M. "Electrophysiological End Point for Catheter Ablation of Atrial Fibrillation Initiated From Multiple Pulmonary Venous Foci," Circulation. 2000;101:p. 1409.
    ¹⁸"In the opinion of the author, the best technique currently available for curing paroxysmal AF (assuming it originates from the pulmonary veins) is segmental isolation of the pulmonary veins by discrete applications of radiofrequency energy at the ostia, guided by pulmonary vein potentials." Scheinman M. "Nonpharmacological Approaches to Atrial Fibrillation," Circulation. 2001:103: p. 2120.
    ¹⁹Prystowsky E. "Management of Atrial Fibrillation: Therapeutic Options and Clinical Decisions,"  The American Journal of Cardiology. Vol. 85 (10A), May 25, 2000, p. 5D.
    ²⁰Olsson S. "Atrial fibrillation - where do we stand today?"  Journal of Internal Medicine. 2001;250: p. 19.
    ²¹Haïssaguerre M. "Successful Catheter Ablation of Atrial Fibrillation," Journal of Cardiovascular Electrophysiology 5 (1994), pp. 1045-1052.
    ²²Natale A. "First Human Experience With Pulmonary Vein Isolation Using a Through-the-Balloon Circumferential Ultrasound Ablation System for Recurrent Atrial Fibrillation," Circulation. 2000;102:pp.1879-1882.
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    ²³Paydek H. "Atrial Fibrillation After Radiofrequency Ablation of Type I Atrial Flutter," Circulation. 1998;98:p.315.
    ²⁴Podrid P. "Oral Antiarrhythmic Drugs Used for Atrial Fibrillation: Clinical Pharmacology," Atrial Fibrillation: Mechanisms and Management, edited by R. H. Falk and P. J. Podrid, Raven Press, Ltd., New York, 1992: p. 200.
    ²⁵Atwood J. "Exercise Hemodynamics of Atrial Fibrillation," Atrial Fibrillation: Mechanisms and Management, 2nd ed., edited by R. H. Falk and P. J. Podrid. Lippincott-Raven Publishers, Philadelphia, 1997: p. 222.
    ²⁶Allessie M. "Pathophysiology and Prevention of Atrial Fibrillation," Circulation. 2001;103(5):769.
    ²⁷Wyndham C. "Atrial Fibrillation The Most Common Arrhythmia," Texas Heart Institute Journal. Vol 27, Number 3, 2000: p. 261.
    ²⁸Brugada R. "Identification of a genetic locus for familial atrial fibrillation," New England Journal of Medicine 1997;336:p. 905-911.
    ²⁹Adams Jr. H. "How To Avoid Stroke," The Good Life. Boardroom Inc., 2001, p. 31.
    ³⁰Los Angeles Cardiology Associates Web site, "Radiofrequency Ablation," p. 4. http://www.lacard.com
    ³¹Segmental vs. Circumferential Ablation Debate, NASPE Convention, San Diego, CA. May 9, 2002.
    ³²www.intelihealth.com (by Aetna)/atrial fibrillation/treatment.
    ³³"Atrial Fibrillation Educational Material," University of Pennsylvania, 2001, p.7
    ³⁴Jais, P. "Ablation Therapy for Atrial Fibrillation: Past, Present and Future," Cardiovascular Research, Vol. 54, Issue 2, May 2002, P. 343.
    ³⁵"...the linear atrial ablation technique (is) more suited for patients with persistent atrial fibrillation and structural heart disease." Haines, D. "Atrial Fibrillation: New Approaches in Management." Un. of Virginia multi-media presentation, 1999, p.6.
    ³⁶Palazzo, Mary O. "The Atrial Fibrillation Page," http://members.aol.com/mazern/afib101.htm, "Prevention of Blood Clot Formation"
    ³⁷Falk, Rodney H. "Atrial Fibrillation," The New England Journal of Medicine, Vol. 344, No. 14, April 5, 2001, p. 1074.
    ³⁸"It's imperative that the patient receive anticoagulation before (electro)cardioversion, as well as a month after cardioversion." Haines, D. "Atrial Fibrillation: New Approaches in Management." Un. of Virginia multi-media presentation, 1999, p. 9.
    ³⁹Fuster, V. "Guidelines for the Management of Patients With Atrial Fibrillation," the American College of Cardiology, the American Heart Association, Inc. and the European Society of Cardiology, Vol. 38, No 4, 2001, p. 19.
    ⁴⁰Pappone, C. et al. "Atrial electroanatomical remodeling after circumferential radiofrequency pulmonary vein ablation. Efficacy of an anatomic approach in a large cohort of patients with atrial fibrillation." Circulation 2001;104:2539-2544.
    ⁴¹Jaïs, P. NASPE Convention presentation, San Diego, CA, May 8, 2002.
    ⁴²Frost L., et al. "Atrial fibrillation and flutter after coronary artery bypass surgery: epidemiology, risk factors and preventive trials." International Journal of Cardiology. 1992;36:253-262.
    ⁴³Coumel P. "Role of the autonomic nervous system in paroxysmal atrial fibrillation." In: Touboul P, Walso AL, eds. Atrial Arrhythmias: Current Concepts and Management. St. Louis, Mo: Mosby-Year Book; 1990:248-261.
    ⁴⁴Allessie, Maurits A. et al. "Pathophysiology and Prevention of Atrial Fibrillation." Circulation. 2001;103:769.
    ⁴⁵Wyse, D. George. "Atrial Fibrillation: The Clinically Relevant Trials and Results." http://www.pslgroup.com/dg/25f9a.htm.
    ⁴⁶New England Journal of Medicine, Volume 336, Number 13, 905, March 27, 1997.
    ⁴⁷Haïssaguerre M et al. "Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins." New England Journal of Medicine. 1998;339;659-666.
     ⁴⁸Chen, SA et al. "Initiation of atrial fibrillation by ectopic beats originating from the pulmonary veins: electrophysiological characteristics, pharmacological responses, and effects of radiofrequency ablation. Circulation. 1999;100:1879-1886.
    ⁴⁹http://www.irondisorders.org/Disorders/ p. 1.
    ⁵⁰http://www.ironoverload.org/facts.html, p. 2.
    ⁵¹http://www.ironoverload.org/diagnosis.html
    ⁵²http://www.newcenturynutrition.com/public_html/webzine/
archives/iron_overload.shtml
    ⁵³http://www.affacts.org/Reseach/pvi_cath_maze.html
    ⁵⁴"Resting potential (RP) was less negative in PV cardiomyocytes, in association with reduced IK1 currents. PVs had smaller maximum phase 0 upstroke velocity (Vmax) due to Na⁺-current inactivation by reduced RP. ...IKr and IKs were greater in PV (by ~60% and ~50% respectively), whereas transient outward K⁺-current (Ito) and L-type Ca²⁺-current (ICa) were significantly smaller (by ~25% and ~30% respectively)."
    ⁵⁵"...antiarrhythmic drug therapy often becomes less effective over time, with approximately half of the patients eventually developing resistance to them. In addition, antiarrhythmic drugs can have severe side effects, including pulmonary fibrosis and impaired liver function." http://www.cardima.com/patients/options.html
    ⁵⁶"Bottom Line Personal," July 15, 2003, p. 10.
    ⁵⁷http://merck.praxis.md/index.asp?page=bpm_report&article_id=
BPM01CA18&section=report&ss=7 Prognosis section
    ⁵⁸Pappone, Carlo et al. "Circumferential Pulmonary Vein Ablation for Atrial Fibrillation: the Milan Experience," Cardiac Electrophysiology and Pacing Unit of the Department of Cardiology, San Raffaele University Hospital, Milan, Italy. 2003. p. 7. "...the term "electroanatomical remodeling" coined by us derives from the fact that circumferential PV ablation, when effective, determines a significant reduction in LA size and improvement in its transport function during follow-up."
    ⁵⁹"Bottom Line Personal," Vol. 25, Number 4, February 15, 2004. p. 9.
    ⁶⁰Boston A-Fib Symposium presentation, January 17, 2004 "PV Isolation vs. Left Atrial Ablation."
    ⁶¹ http://www.londonafcentre.co.uk Symptoms, Signs and Risks, citing from the Framingham study.
    ⁶²http://www.londonafcentre.co.uk Treatment Options, Drugs.
    ⁶³http://www.londonafcentre.co.uk Treatment Options, Catheter Ablation.
    ⁶⁴http://www.rwjuh.edu/medical_services/
min_invasive_atrial_fibrillation.html. Robert Wood Johnson University Hospital, The Heart Center of New Jersey.
    ⁶⁵http://www.freewebs.com/lasalocid
    ⁶⁶James L. Cox, "The Role of Surgical Intervention in the Management of Atrial Fibrillation," Texas Heart Institute Journal, 2004; 31 (3): 257-265.
    ⁶⁷Garcia-Fernandez, Journal of American College of Cardiology 42:1253-8, 2003
    ⁶⁸Go, "Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention." JAMA, 2001:285:2370-2375.
    ⁶⁹Arch Intern Med 1987;147:1561-1564.
    ⁷⁰Feinberg, "Prevalence, age distribution, and gender of patients with atrial fibrillation: analysis and implications." Arch Intern Med 1995;155:469-473.
    ⁷¹Go, "Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention." JAMA, 2001:285:2370-2375.
    ⁷²Feinberg, "Epidemiological features of asymptomatic cerebral infarction in patients with nonvalvular atrial fibrillation." Arch Intern Med 1990;150:2340-2344.
    ⁷³Fuster, "ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation." J Am Coll Cardiol 1002;38:1231-1266.
    ⁷⁴van Walraven, "Oral anticoagulants vs aspirin in nonvalvular atrial fibrillation." JAMA 2002;288:2441-2448.
    ⁷⁵Hylek, "Risk factors for intracranial hemorrhage in outpatients taking warfarin." Ann Intern Med 1994 120:897-902.
    ⁷⁶Camm, "Clinical Relevance of Silent Atrial Fibrillation: Prevalence, Prognosis, Quality of Life, and Management." Journal of Interventional Cardiac Electrophysiology 4, 369-382, 2000, p. 373.
    ⁷⁷"...there is a three-fold risk of developing heart failure in the presence of AF." Camm, "Clinical Relevance of Silent Atrial Fibrillation: Prevalence, Prognosis, Quality of Life, and Management." Journal of Interventional Cardiac Electrophysiology 4, 369-382, 2000, p. 376.
    ⁷⁸Camm, "Clinical Relevance of Silent Atrial Fibrillation: Prevalence, Prognosis, Quality of Life, and Management." Journal of Interventional Cardiac Electrophysiology 4, 369-382, 2000, p. 377.
    ⁷⁹"Atrio-esophageal fistula, thus far reported only after circumferential pulmonary vein ablations, may be related to the more extensive ablation lesions applied to the posterior left atrium." Prystowsky, "AF Ablation as First-Line Therapy." Circulation 2005;112:1214-1231, p. 1227.
    ⁸⁰Prystowsky, "Should atrial fibrillation ablation be considered first-line therapy for some patients?" Circulation 2005;112:1214-1231, p. 1228.
    ⁸¹Ritchie, James "UC doctor rebuked for not divulging financial tie to ArtiCure." Cincinnati Business Courier, December 28, 2005, http://cincinnati.bizjournals.com/cincinnati/stories/2005/12/26/daily12.html.
    And Armstrong, David "Surgery Journal Threatens Ban For Authors' Hidden Conflicts." The Wall Street Journal, December 28, 2005.
    ⁸²Van Wagoner, David "Atrial selective strategies for treating atrial fibrillation." Drug Discovery Today: Therapeutic Strategies Vol 2, No. 3, 2005. "We have detected increased levels of the systemic inflammatory marker C-reactive protein (CRP) in patients with A-Fib."
    ⁸³Wazni, "Radiofrequency ablation vs. antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation: a randomized trial." J. Am. Med. Assoc. 2005:293,2634-2640.
    ⁸⁴Frustaci, A., "Histological substrate of atrial biopsies in patients with lone atrial fibrillation." Circulation 1997;96:1180-1184.
    ⁸⁵Dernellis, J.M., "Relationship between C-reactive protein concentrations during glucorticoid therapy and recurrent atrial fibrillation." Eur. Heart J. 2004;25: 1100-1107.
    ⁸⁶Van Wagoner, David. "Basic mechanisms of atrial fibrillation." Cleveland Clinic Journal of Medicine, Vol. 70, Supplement 3, July, 2003.
    ⁸⁷Packer.
    ⁸⁸Keane, David. "Emerging Concepts on Catheter Ablation of Atrial Fibrillation from the Tenth Annual Boston Atrial Fibrillation Symposium." J Cardiovasc Electrophysiol. Vol. 16.pp.1025-1028, September 2005.
    ⁸⁹"The tallest patients in a recent study were 32% more likely to have A-Fib than the shortest ones. Doctors estimate that for every six-inch increase in height, the risk for A-Fib increases by 50%." Bottom Line Health, July, 2006, p. 14.
    ⁹⁰http://patients.uptodate.com/topic.asp?file=hrt_dis/4882
   ^{91http://www.post-gazette.com/pg/05346/621193.stm
    92}Haïssaguerre, et al. "Catheter Ablation of Long-Lasting Persistent Atrial Fibrillation: Clinical Outcome and Mechanisms of Subsequent Arrhythmias." Journal of Cardiovascular Electrophysiology, Vol. 16, November 2005, pp. 1138-47.Haissaguerre M, Hocini M, Sanders P, Sacher F, Rotter M, Takahashi Y, Rostock T, Hsu LF, Bordachar P, Reuter S, Roudaut R, Clementy J, Jais P.
Hopital Cardiologique du Haut-Leveque, Bordeaux-Pessac, France. jacques.clementy@pu.u-bordeaux2.fr

BACKGROUND: Catheter ablation of atrial fibrillation (AF) is challenging in patients with long-standing persistent AF. The clinical outcome and subsequent arrhythmia recurrence after using an ablation method targeting multiple left atrial sites with the aim of achieving acute AF termination has not been characterized. METHODS: Sixty patients (mean age: 53 +/- 9 years) with persistent AF (mean duration: 17 +/- 27 months) were prospectively followed after catheter ablation. Catheter ablation targeting the following sites was performed in a random sequence: (i) electrical isolation of all pulmonary veins (PV); (ii) disconnection of other thoracic veins; (iii) atrial ablation at sites possessing complex electrical activity, activation gradients, or short cycle lengths. Finally, linear ablation of the LA roof and mitral isthmus was performed if sinus rhythm was not restored following energy delivery to the above sites. At 1, 3, 6, and 12 months after ablation, patients underwent clinical review and 24-hour ambulatory ECG monitoring to identify asymptomatic arrhythmia. Repeat mapping and catheter ablation was performed in any patient experiencing recurrent atrial tachycardia (AT). Clinical success was defined as the absence of any sustained atrial arrhythmia. RESULTS: AF terminated during ablation in 52 patients (87%). The fluoroscopy and procedural durations were 84 +/- 30 minutes and 264 +/- 77 minutes, respectively. Three months after ablation, sustained ATs were documented in 24 patients (associated with AF in 2). Mapping in 23 patients showed a single AT in 7 while multiple ATs were observed in 16. Macroreentry was confirmed to be due to gaps in the ablation lines, while focal ATs originated from discrete sites or isthmuses near the left atrial appendage, coronary sinus, pulmonary veins, or fossa ovalis; these sites were similar to those at which the greatest impact was observed on the fibrillatory process during the initial ablation procedure. After repeat ablation, at 11 +/- 6 months of follow-up, 57 patients (95%) were in sinus rhythm and 3 developed recurrent AF or AT. All patients in sinus rhythm demonstrated improved exercise capacity and all but 2 had evidence of atrial transport as assessed by Doppler echocardiography (mitral A wave velocity 34 +/- 17 cm/sec) by 6 months. CONCLUSION: Catheter ablation of long-lasting persistent AF associated with acute AF termination achieves medium to long-term restoration and maintenance of sinus rhythm in 95% of patients. Arrhythmia recurrence in the majority of patients is AT.
    ⁹³Mantovan et al. "Comparison Between Anatomical and Integrated Approaches to Atrial Fibrillation: Adjunctive Role of Electrical Pulmonary Vein Disconnection."Journal of Cardiovascular Electrophysiology. Vol. 16, December, 2005. pp. 1293-1297.
    ⁹⁴http://www.medscape.com/pages/editorial/pressreleases/pr-crm-stereotaxis4
    ⁹⁵"Phrenic nerve injury after atrial fibrillation catheter ablation: characterization and outcome in a multicenter study." Sacher, Journal of American Cardiology, 2006 Jun 20; 47(12): pp. 2498-503.
    ⁹⁶http://www.marketwatch.com/news/story/first-visually-guided-catheter-ablation/story.aspx?guid={7B6E0E64-238B-4E8D-94CB-392793779250}&print=true&dist=printTop
    ⁹⁷ "Atrial reduction plasty Cox maze procedure: extended indications for atrial fibrillation surgery." Bolling, Ann Thorac Surg 2004;77:1282-1287. http://ats.ctsnetjournals.org/cgi/content/abstract/77/4/1282.
    ⁹⁸"Atrial Fibrillation Is Associated With Lower Cognitive Performance in the Framingham Offspring Men." Elias, Journal of Stroke and Cerebrovascular Diseases, Vol. 15, No. 5 (September-October), 2006: pp. 214-222.
    ⁹⁹"Chronic atrial fibrillation and low cognitive function: Letters to the editor." Rozzini, Stroke 1999;30:109-191.
    ¹⁰⁰"Atrial fibrillation and dementia in a population-based study: The Rotterdam study." Ott, Stroke 1997;28:316-321.
    ¹⁰¹http://www.afibcryoablation.com/cryoablation.asp
    ¹⁰² Tse et al. Journal of Interventional Cardiac Electrophysiology, 2001;5:167-172.
    ¹⁰³Cardiovascular Physiology Concepts by Richard E. Klabunde, Lippincott, Williams and Wilkins, 2004. http://www.cvphysiology.com/Arrhythmias/A006.htm
    ¹⁰⁴"Importance of Geometry and Refractory Period in Sustaining Atrial fibrillation: Testing the Critical Mass Hypotheses." Byrd et al. Circulation 2005; DOI: 10.1161/CirculationAHA.104.526210.
    ¹⁰⁵Briston-Meyers Squibb Company Medication Guide for Coumadin FDA approved NDA 9218/S-105, p. 13. http://www.fda.gov/cder/foi/label/2007/009218s105lblv2.pdf
    ¹⁰⁶ Gillinov AM, Blackstone EH, et al. "Atrial Fibrillation: Current surgical options and their assessment." Ann. Thorac. Surg. 2002; 74:2210-17.
    ¹⁰⁷ Blackshear JL, Odell JA. "Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation." Ann. Thorac. Surg. 1996;61:755-759.
    ¹⁰⁸http://www.medscape.com/viewarticle/406272_3
    ¹⁰⁹"In fact, those (rate control) drugs, which are quite valuable in achieving ventricular rate control, have not been shown in placebo-controlled studies to restore sinus rhythm." Alpert, Martin A. "Medical Cardioversion of Atrial Fibrillation" Chest 2000;117:1529-1531, http://www.chestjournal.org/cgi/content/full/117/6/1529
    ¹¹⁰ Sopher, Malik and Camm, "Neural Aspects of Atrial Fibrillation," in Atrial Fibrillation: Mechanisms and Management, Falk and Podrid ed., Lippincott and Raven, 1997, p. 159.
    ¹¹¹ "Vagally Mediated Paroxysmal Atrial Fibrillation--A Patient's View, Victor Thuronyi. http://www.afibbers.org/victor2.html
    ¹¹²Gorman, Christine, "A Candidate's Racing Heart," TIME, Sunday, Dec. 12, 1999. http://www.time.com/time/printout/0,8816,35831,99.html
    ¹¹³Los Angeles Times, November 27, 2007, p. A14.
    ¹¹⁴Camm, "Stroke in atrial fibrillation: Update on pathology, new antithrombotic therapies, and evolution of procedures and devices." Annals of Medicine, 39:5, 371-391, 2007
    ¹¹⁵Turpie, "New oral anticoagulants in atrial fibrillation." European Heart Journal advanced publication 12/19/07
    116Oral et al: "Risk of Thromboembolic Events After Percutaneous Left Atrial Radiofrequency Ablation of Atrial Fibrillation."Circulation 2006;114:759-763.
    ¹¹⁷http://www.dhmc.org/webpage.cfm?site_id=2&org_id=108&morg_id=0&sec_id=0&gsec_id=39685&item_id=39691
    ¹¹⁸http://www.theheart.org/article/876771.do
    ¹¹⁹The PAFAC study. Fetsch at al: European Heart Journal, 2005.
    ¹²⁰Singh BN: New England Journal of Medicine 2007;357: 987-999.
    ¹²¹Wazni OM et al: JAMA 2005; 293:2634-2400.
    ¹²²Stabile G et al: European Heart Journal 2006; 27:216-221,
    ¹²³Pappone C et al: J Am Coll Cardiol  2006; 48: 2340-47.
    ¹²⁴ A report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation.
    Developed in partnership with the European Heart Rhythm Association (EHRA) and the European Cardiac Arrhythmia Society (ECAS); in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Endorsed and Approved by the governing bodies of the American College of Cardiology, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, and the Heart Rhythm Society.
    ¹²⁵Calkins H, Brugada J, Packer DL et al. HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures, and follow-up. Heart Rhythm Society 2007 Scientific Sessions; May 9, 2007: Denver, CO. DOI: 10.1016/j.hrthm.2007.04.005
    ¹²⁶http://www.medscape.com/viewarticle/568210
    ¹²⁷Gramley, F. J. Journal of Cardiovascular Electrophysiology, 2007. 18: 1076-82.
    ¹²⁸Heckbert, Susan. Bottom Line Personal, Vol. 29, Number 16, August 15, 2008, p. 1.
    ¹²⁹ http://www.theheart.org/article/939929.do
    ¹³⁰ http://www.wolfminimaze.com/physicianinfo.html
    ¹³¹ Hans Larson, ^"The AFIB Report." Number 87, March 2009, p. 11.
    ¹³² http://www.lifeextensionvitamins.com/cadico6otco.html
    ¹³³ http://www.lifeextensionvitamins.com/cadico8thc.html
    ¹³⁴ http://www.lifeextensionvitamins.com/cadico13thps.html
    ¹³⁵ http://www.lifeextensionvitamins.com/cadico14thvz.html (Sinatra, 1997)
    ¹³⁶ http://www.lifeextensionvitamins.com/cadico9thde.html
    ¹³⁷ http://www.lifeextensionvitamins.com/cadico11thh.html
    ¹³⁸ Steinberg JS et al. "Value of the P-wave signal-averaged ECG for predicting atrial fibrillation after cardiac surgery." Circulation, Vol. 88, 2618-2622, 1993.
    ¹³⁹  http://www.theheart.org/article/966981.do
    ¹⁴⁰ Furberg CD et al. "Prevalence of atrial fibrillation in elderly subjects (the Cardiovascular Health Study)." Am J Cardiol. 1994; 74: 236-241.
    ¹⁴¹ Abdon NJ et al. "Is occult atrial disorder a frequent cause of non-hemorrhagic stroke? Long term ECG in 86 patients." Stroke. 1982; 13: 832-837.
    ¹⁴² Schuchert A et al. "Impact of long-term ECG recording on the detection of paroxysmal atrial fibrillation in patients after acute ischemic stroke." Pacing Clin Electrophyiol. 1999' 22" 1082-1084.
    ¹⁴³ Rashid, Abdul et al. "The effects of caffeine on the inducibility of Atrial fibrillation." J Electrocardiol. 2006 October, 39(4): 421-425. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2257921
    ¹⁴⁴ http://www.medscape.com/viewarticle/501279?src=search
    ¹⁴⁵ http://www.ajcn.org/cgi/content/full/81/3/539
    ¹⁴⁶ Nelson, Bryn. "Places In The Heart," NYU Physician. Spring, 2009, p. 8.
    ¹⁴⁷ Paluska SA. "Caffeine and exercise." Curr Sports Med Rep 2003;2:213-9
    ¹⁴⁸ Myers MG. "Caffeine and cardiac arrhythmias." Ann Intern Med 1991;114:147-         ¹⁵⁰ Damiano, Jr., RJ. "What Is the Best Way to Surgically Eliminate the Left Atrial Appendage?" Journal of the American College of Cardiology 2008, Sept. 9; Vol. 52, No. 11:930-1.
    ¹⁵¹ http://www.prweb.com/printer/2396634.htm
    ¹⁵² Unda #8. Cardiovascular, Heart Meridian
    This remedy is indicated for conditions affecting the arterial and venous circulation, such as angina pectoris, disorders of venous circulation (varices, phleda 8 acts profoundly on the pericardium and also provides deep angiocardiac drainage. Because it has a deep action on the heart, it is effective in all pathologies of cardiac function, both arterial and venous.
 bitis), hemorrhoids, obliterative arteritis and arteriosclerosis.
    Un
Formula # Achillea millefolium (Yarrow).......4 X
# Cactus grandiflorus (Night Blooming Cereus).......4 X
# Crataegus oxyacantha (Hawthorn).......4 X
# Equisetum arvense (Horsetail).......4 X
# Hamamelis virginiana (Witch Hazel).......4 X
# Mercurialis perennis (Dog Mercury).......4 X
# Thlaspi bursa-pastoris (Shepherd's Purse).......4 X
# Cuprum metallicum (Copper).......12 X
* Contains 25% alcohol

Recommended Dosage Adults: 5 drops three times daily.
Acute conditions: 5 drops six times daily.
Children under 12: 3 to 5 drops three times daily.
    ¹⁵³ Cardiovascular Insufficiencies
    Unda 248 is the most important remedy for the arterial circulation, due to its ability to affect arterial elimination. This remedy is indicated for conditions such as cardiac insufficiency, arrythmia, extrasystole, tachycardia, disturbances of the aortic circulation, and arterial congestion. N.B. This remedy should always be used in combination with Unda 8 (its complementary remedy on the level of circulation and blood).

Formula
* Crataegus oxyacantha (Hawthorn) 4 X
* Magnolia glauca (Sweet Magnolia) 4 X
* Passiflora incarnata (Passionflower) 4 X
* Strophanthus gratus (Strophanthus) 4 X

Recommended Dosage
Adults: 5 drops three times daily.
Acute conditions: 5 drops six times daily.
Children under 12: 3 to 5 drops three times daily.
    ¹⁵⁴ http://www.elements4health.com/breakthrough-study-links-heart-disorder-and-alzheimers.html
    ¹⁵⁵ http://en.wikipedia.org/wiki/Vitamin_K
    ¹⁵⁶ Eby, George et al. "Elimination of cardiac arrhythmias using oral taurine with L-arginine with case histories: Hypothesis for nitric oxide stabilization of the sinus node." Medical Hypotheses. Elsevier Ltd. doi:10.1016/j.mehy.2006.04.055. http://george-eby-research.com/html/taurine-l-arginine-arrhythmias.pdf
    ¹⁵⁷ "Screening and Management of Amiodarone Toxicity" Heist & Ruskin, Cardiac Arrhythmia Service, Massachusetts General Hospital, p. 6.
    ¹⁵⁸ http://www.theheart.org/article/998617.do
    ¹⁵⁹ MediFocus Guide "Atrial Fibrillation." #CR004, July 10, 2009. p.38.
    ¹⁶⁰ MidiFocus Guide "Atrial Fibrillation." #CR004m July 10, 2009. p. 40.
    ¹⁶¹ http://www.healthsciences.utah.edu/carma/Atrial_Fibrillation_FAQ.html
    ^{162 http://www.heartrhythmspecialist.co.uk/Heartrhythmspecialist.co.uk/AF__Ablation_or_drugs.html
    163} Bottom Line Health, Vol. 23, Number 12, December, 2009. p. 1.
    ¹⁶⁴ http://www.caifl.com/atrial-fibrillation.html "AF can also cause a fast pulse rate for a prolonged period, which can weaken the ventricular heart muscle over time, and lead to heart failure."
    ¹⁶⁵ http://www.skillstat.com/heartscape/chambers.htm "Atrial kick - the contraction of the atria prior to the contraction of the ventricle accounts for more volume (1/3 more) to the ventricle and more muscle stretch. With Starling's Law at play, atrial kick accounts for 15-30% of blood ejected. Note that the older one becomes, the higher the percentage owed to atrial kick. For example, for the elderly with only quivering atria - atrial fibrillation - they are often more effected because as much as a third of their blood supply to ALL of their cells has been eliminated."
    ¹⁶⁶ ACC/AHA/ESC. 2006 "Guidelines for the Management of Patients with Atrial Fibrillation." Circulation, 2006;114:700-752. The mortality rate of patients with A-Fib is about double that of patients with normal sinus rhythm and is linked to the severity of underlying heart disease. 
    ¹⁶⁷http://stroke.ahajournals.org/cgi/content/full/strokeaha;28/2/311
    ¹⁶⁸http://www.loftusmd.com/Articles/stroke/atrialfibrillation.html
    ¹⁶⁹ Marrouche, Nassir F. et al. Circulation, 2009; 119; 1758-1767.
    ¹⁷⁰ http://www.stopafib.org/newsitem.cfm/NEWSID/120
    ¹⁷¹ Bunch, TJ et al. J Cardiovasc Electrophysiol. 2009 Sept;20(9):988-93.http://www.ncbi.nlm.nih.gov/pubmed/19473299
    ¹⁷² Macle, L et al. "Radiation Exposure During Radiofrequency Catheter Ablation for Atrial Fibrillation." Pacing and Clinical Electrophysiology, March 28, 2003. Volume 26, Issue 1p2, Pages 288-291.
    ¹⁷³ http://www.unscear.org/docs/reports/gareport.pdf
    ¹⁷⁴ H. Calkins et al. "Radiation exposure during radiofrequency catheter ablation of accessory atrioventricular connections." Circulation, Vol. 84, 2376-2382, 1991.
    ¹⁷⁵ Shapira, Adam R., "Catheter Ablation of Supraventricular Arrhythmias and Atrial Fibrillation." American Family Physician, November 15, 2009, p. 1089. http://www.aafp.org/afp/2009/1115/p1089.html
    ¹⁷⁶ Efstathopoulos et al. "Patient and staff radiation dosimetry during cardiac electrophysiology studies and catheter ablation procedures: a comprehensive analysis." Europace (The European Society of Cardiology), 2006 8(6): 443-448; doi:10.1093/europace/eul041



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