TREATMENTS FOR ATRIAL FIBRILLATION

    Before discussing any treatments, your first priority if you have A-Fib, is to consult with your doctor about taking a blood thinner: (anticoagulants like warfarin, Coumadin, Jantoven or antiplatelets like Aspirin, Ecotrin, Plavix, Ticlid, or the newer blood thinner dabigatran [Pradaxa]). Because the upper part of your heart isn't pumping out properly, blood clots can form and travel to your brain causing stroke.  A stroke can cause paralysis, loss of vision, speech, hearing, mental faculties, and can make life miserable. An A-Fib stroke is often a fate worse than death. (For more detailed info on the risk of an A-Fib stroke, see Odds of Getting an A-Fib Stroke).
    If you cannot tolerate blood thinners or don't want to take them, a possible option to prevent A-Fib stroke is to have a device installed to close off the Left Atrial Appendage where 90-95% of A-fib strokes come from (Watchman and Amplatzer currently in clinical trials). Then you would usually not need to be on blood thinners. For a partial list of doctors installing the Watchman device, see Doctors Installing the Watchman Device.
    (Added 4/12/2011): Removing or closing off the Left Atrial Appendage (LAA) may affect how well the heart pumps and is of special concern to athletes and to those with heart pumping problems. In canine studies the LAA provided 17.2% of the whole left atrial volume of blood pumped.²⁵⁷ It's possible that removing or closing off the LAA may lead to heart pumping problems. The LAA is like a surge tank on a hot water heater. When the Mitral Valve closes, the LAA absorbs the surge of blood. When the LAA is amputated or closed off, this may cause increased pressure in the Pulmonary Veins and exercise intolerance. Few, if any, centers currently perform pre- and post-amputation exercise testing.)
    (Added 4/7/11) The FDA has approved a noose-like device that completely closes off the Left Atrial Appendage which dies and is no longer electrically active. See Lariat II.)
    (Added 11/30/10:) The FDA recently approved a new blood thinner called dabigatran (brand name Pradaxa) which is as effective or even more effective than warfarin without many of the accompanying problems of warfarin. It will probably replace warfarin as the blood thinner of choice for A-Fib. See Dabigatran to Replace Warfarin and Dabigatran Now Available in Pharmacies. But see also Dabigatran (Pradaxa) Indigestion, Burning, Stomach Pain, (Weight Loss) Side Effects.)
    Dabigatran (brand name Pradaxa) is a direct thrombin inhibitor, a newer type of medication. Thrombin is an enzyme that converts soluble fibrinogen into insoluble fibrin. Fibrin is a fibrous protein involved in the clotting of blood. It forms a mesh or clot over a wound.

    Current treatments for A-Fib are:

• "Natural" Remedies
• Medications
      Pill-In-The-Pocket Treatment
• Chemical Cardioversion
• Electrical Cardioversion
• Ablation or Modification of the Atrioventricular (AV) Node and Implementation of a Pacemaker
• The Maze and Mini Maze Surgical Operations
• Permanent Pacemaker Therapy
• Implantable Defibrillator
• Pulmonary Vein Ablation (Isolation)
• Decisions---Guidelines for Choosing the Treatment That's Right for You

"NATURAL" REMEDIES

    When you have A-Fib, a sensible starting point may be to check for chemical imbalances or deficiencies. A deficiency in minerals like magnesium or potassium (electrolytes) can force the heart into fatal arrhythmias.¹³³
    Warning: consult with your doctor before adding any minerals or supplements to your treatment plan. They may interfere or interact with the medications you are taking. In addition, you may need closer medical supervision while taking minerals and/or supplements.
    Unfortunately a great number of physicians are not well versed in recommending or supervising nutritional support and quite often, will dismiss your inquiries about nutritional supplements.²⁰⁰ You may need to work with your doctor to determine the benefit of  nutritional supplements for your A-Fib health.
    Specific health supplements and how to obtain them are mentioned only as a convenience for readers. A-Fib.com has no financial ties to supplement distributors.
    Anything you can do to improve your overall health---exercise, diet, avoiding A-Fib triggers, etc.---may also help or reduce A-Fib symptoms and attacks.

 MAGNESIUM

    "Anyone in A-Fib is almost certainly magnesium deficient."¹⁸⁸ While Magnesium (Mg) is one of the main components of heart cell functioning, it seems to be chronically lacking in most diets. "Magnesium deficiencies range from 65% to 80% in general populations in the US and globally.^"187 Most US adults ingest only about 270 mg of magnesium a day, well below the modest magnesium RDAs of 420 mg for adult males and 320 mg for adult females. This creates a substantial cumulative deficiency over months and years.¹⁹⁰ (See also Magnesium Success Stories and Magnesium Importance for A-Fib.)
    One method of determining your magnesium levels is the diagnostic tool "EXAtest" (http://www.exatest.com) which tests for intracellular rather than serum (in the blood) magnesium concentration. A normal lower limit is 33.9 mEq/IU¹⁹¹. (Serum Magnesium levels aren't good indicators of how much Magnesium is actually present and working within cells. Serum levels of magnesium remain relatively stable [about 1%], even though working intracellular magnesium levels may be low.) Unfortunately few doctors provide this test. But if you have A-Fib, you can take for granted that you need more Magnesium.²⁷⁸
    A more common test is the Red Blood Cell (RBC) Magnesium analysis, though it may not be as accurate as the EXAtest.

WHAT KIND OF MAGNESIUM?
    Four forms of easily absorbed magnesium are:
    * Magnesium Glycinate: a chelated amino acid. Look for the label "Albion Minerals." This is a patented process designed to limit bowel sensitivity. One source is "Doctor's Best High Absorption 100% Chelated Magnesium" available from http://www.iherb.com.
    * Angstrom Magnesium: such as "New Beginnings Liquid Magnesium - Ionic Liquid Concentrate," available from http://www.evitalhealth.com
    * Intravenous (IV) Magnesium Sulfate: This is the fastest way to restore normal heart rhythm. It is a recognized therapy worldwide,^{276, 277} but not generally in the US.²⁴⁰ Dr. Julian Whitaker in Newport Beach, CA performs this therapy---http://www.drwhitaker.com/conditions-concerns/.
    * Slow Release Jigsaw Magnesium w/SRT (Sustained Release Technology) with Albion organic dimagnesium malate to limit bowl sensitivity. (Thanks to June Irwin for making us aware of this product.)  http://www.jigsawhealth.com/supplements/magnesium

 DOSAGE
    A recommended goal is a minimum 600 mg/day, preferably 800 mg. (For example, 200mg three times a day and 200 mg at bedtime.)²⁸⁸
    It's prudent to start off with very low doses of oral magnesium such as 100 mg. (Excess magnesium or magnesium sensitivity can cause loose stools and diarrhea which is counterproductive, because of the loss of electrolytes.) Increase the dosage of magnesium every 4-5 days. It may take as long as six months to replenish your intracellular magnesium levels.¹⁹²

ORAL MAGNESIUM ALTERNATIVES   
    If oral magnesium causes bowel sensitivity, an alternative (or an additional source of magnesium) is Magnesium Oil which is applied to the skin and over the heart. An example is "Ancient Minerals Ultra Pure Magnesium" which is odorless. Available from AliveAndAware.net. (One method is to apply a drop the size of a quarter to the inner arm fold opposite and above the elbow, then wash off in 20 minutes. )
    Another alternative treatment is Epsom Salts Baths---soak for 20 minutes in a bath with 2 cups of Epsom Salts. (Epsom Salt Baths can also cause loose stools.) See Personal Experiences section Epsom Salts Cure. You can also make an Epsom Salts spray---one part Epsom Salts to one part water. Place in a spray bottle and mist the chest. Let it dry on the skin.

WARNING: DANGER OF TOO MUCH CALCIUM !
    Too much calcium (Ca) can excite the heart cells and induce A-Fib, especially when magnesium is deficient.¹⁹² Calcium supplements may increase heart disease risk by interfering with the absorption or utilization of magnesium.²⁸² According to Dr. Andrea Natale, calcium overload is the primary factor in A-Fib remodeling.¹⁹⁶
    A-Fib patients may need to stop or lower significantly their calcium supplements and increase magnesium.^{195, 279}  Aim for a ratio of one part Calcium to one or more parts Magnesium. It's good to keep track of how much Calcium you are taking in daily, so that you can be sure to take in more Magnesium.

POTASSIUM

    Potassium (K+) is often the second key nutrient A-Fibers may be deficient in. In fact, magnesium depletion can lead to potassium depletion.¹⁹³ Potassium helps prevent A-Fib by prolonging the refractory period---the time when the heart is resting between beats. (During this rest period the heart can't be stimulated to contract, thus leaving the heart in normal sinus rhythm.) When potassium levels are too low, heart cells become unusually excitable, often leading to premature contractions and/or A-Fib.¹⁹⁴
   
DOSAGE
    The recommended dosage is 1600-2400 mg/day. While potassium is available in tablets, the 99 mg maximum dosage makes them impracticable (requiring 16+ tablets a day). Instead the powder form---Potassium Gluconate powder is recommended. Available from iherb.com. Take a total of 3-4 teaspoons a day with meals (approximately 540 mg per teaspoon).²⁸⁹
    But as with magnesium, start off low, one teaspoon/day, and increase the dosage every 4-5 days. The goal is to keep the serum blood potassium level at 4.5 but under 5.0.¹⁹²
    A word of caution---adding too much potassium too soon will make A-Fib worse, not better.¹⁹² Too much potassium in blood plasma makes the cardiac cells depolarized and unexcitable, leading to spontaneous activity in other areas of the heart such as the Pulmonary Vein openings.¹⁹⁴

WARNING
    Please be advised that, before taking magnesium and/or potassium, you should check with your doctor and be tested to determine your current levels.

RECOMMENDED SUPPLEMENTS FOR HEART RHYTHM PROBLEMS_:¹³⁵
    TAURINE
    COENZYME Q10
    L-CARNITINE
    FISH OIL
   RIBOSE (D-RIBOSE)¹⁹⁷
    HAWTHORNE BERRY
   Vitamin D (Added 2/16/11: Doctors at Intermountain Medical Center in Utah have identified Vitamin D deficiency as contributing to the development of both A-Fib and Dementia. See A-Fib and Dementia.)
    Because the above supplements occur naturally, they can not be patented by drug companies and are not pharmaceuticals. Natural remedies are often not submitted to rigorous double-blind studies with large populations such as the FDA requires for medications. That doesn't mean these remedies aren't effective for A-Fib, but only that the level of proof of their effectiveness is different.
    Consult with your doctor before adding any supplements to your treatment plan. They may interfere or interact with the medications you are taking.

TAURINE

    Taurine along with magnesium and potassium have been described as "the essential trio" for treating nutritional deficiencies relating to A-Fib.²⁰²
    Taurine is a sulfur-containing amino acid and is the most important and abundant amino acid in the heart. It regulates membrane excitability, scavenges free radicals, protects potassium levels inside the heart, and dampens activity in the sympathetic nervous system.¹³⁵ Taurine regulates cellular calcium, improves heart muscle contraction, and also prevents the heart from becoming overly irritable, which can lead to heart rhythm problems.²⁰¹
    CAUTION: Food additives such as monosodium glutamate (MSG) and the artificial sweetener aspartame lower the body's concentration of taurine.²⁰¹

DOSAGE
    3,000 mg per day in divided doses with meals.¹⁹² (No brand preference.)

COENZYME Q10 (UBIQUINONE)

    Coenzyme Q-10 is a naturally occurring enzyme, part of the quinone chemical group, that is found in every cell in the body. It plays a key role in producing energy in the mitochondria. CoQ10's  ability to energize the heart is perhaps its chief attribute. 95% of the body's energy is generated by CoQ10, which generates energy in the form of ATP.¹⁹⁹ CoQ10 improves heart functions and heart rhythm problems.¹⁸⁵
    Dr. Sinatra calls Coenzyme Q10 "the spark of life." In heart cells CoQ10 provides the spark that initiates the energy process.²⁰³ It prolongs the action potential and helps maintain sinus rhythm. It's also a powerful antioxidant.
    CAUTION: Be advised that taking statin drugs reduces CoQ10 levels. A CoQ10 deficiency is associated with illness and death in animals.¹³³

DOSAGE
    100-300 mg daily in divided doses with meals.¹⁸⁵ (No brand preference, but the CoQ10 should have "Ubiquinol" on the label. This is a more readily absorbed form of CoQ10.)

L-CARNITINE

    L-Carnitine is a vitamin-like nutrient. It's a derivative of the amino acid lysine which helps to turn fat into energy. It is considered by some to be the single most important nutrient in cardiac health. It reduces the incidence of cardiac arrhythmias and premature ventricular contractions (PVCs).¹³³ Dr. Sinatra says Coenzyme Q10 and Carnitine work together, and calls them the "twin pillars of heart health."²⁰⁴ While CoQ10 ignites the spark that generates ATP, L-Carnitine is the energy shuttle that transports long-chain fatty acids to the heart cells (mitochondria) where they are burned as fuel.

DOSAGE
    750-2000 mg of L-Carnitine Fumerate daily (250 to 500 mg three to four times a day). (No brand preferences.) A newer form "propionyl-L-carnitine (PLC)" targets heart tissue specifically.²⁰⁶

FISH OIL

    Fish Oil/Essential Fatty Acids (EPA and DHA are essential nutrients obtained primarily from eating fish or from supplements.) DHA plays a crucial role in brain function, as well as in normal growth and development. Essential fatty acids like EPA and DHA are considered by some to be natural defibrillators, lessening the incidence of cardiac arrhythmias and A-Fib.¹³⁶ "DHA in particular helps stabilize the heart’s electrical activity, reducing risk of fatal arrhythmias and sudden cardiac death. (In one experiment, Harvard researchers added different toxins to heart cell cultures that caused them to beat erratically. However, when they added omega-3 fatty acids at the same time, arrhythmias were prevented.)^"185
    Try to find a Fish Oil that includes the supplement Gamma E (d-Alpha Tocopherol) to prevent oxidation of the oil once it reaches the tissue.²⁰⁶

DOSAGE
    2,000-8,000 mg daily, liquid or tablets, in divided doses.¹⁸⁵  
    * Source Naturals' "Arctic Pure DHA" liquid, available from iherb.com, tablets iherb.com
    * Nutricology "DHA Fish Oil Concentrate" available from SupplementWarehouse.com

ribose (D-RIBOSE)

    Ribose (D-Ribose) is a five-carbon sugar that is a regulator in the production of ATP. It's a carbohydrate that is the backbone of genetic materials, and it's needed in the production of many metabolic compounds. "The heart's ability to maintain energy is limited by one thing---the availability of ribose."
    Ribose increases tolerance to cardiac stress, improves exercise tolerance and physical function, provides cardiac energy needed to maintain normal heart function, increases cardiac efficiency, lowers stress during exercise, and maintains healthy energy levels in heart and muscle.²⁰⁵

DOSAGE
    7-10 grams of Ribose powder daily. Take in divided doses with meals or just before and after exercise. (No brand preferences.) ¹⁹⁷
    When first starting Ribose, start with small doses at first, then increase gradually.

HAWTHORNE BERRY

    Hawthorne Berry Extract is made from the tiny red berries of the Hawthorne Shrub, and has been used in traditional medicine since ancient times. It reduces tachycardias and palpitations and prevents premature ventricular contractions (PVCs). Hawthorne Berry can energize the heart without prompting arrhythmias. It has a normalizing effect upon the heartbeat.¹³⁷

DOSAGE
    4,500 mg daily in divided doses (three 510 mg capsules three times a day¹⁹⁸), by MSS/Pro available from  HealthRemedies.com.

BCAA+G
    Another possible natural remedy for A-Fib is Branched Chain Amino Acids (BCAA) coupled with L-Glutamine. See BCAA+G Success Stories.

DOSAGE
2 teaspoons of BCAA+G powder in the morning and evening. By Metabolic Response Modifiers BCAA+G with Vitamin B6 2 mg, L-Leucine 2,500 mg, L-Valine 1,500 mg, L-Isoleucine 1,000 mg, L-Glutamine 1,000 mg. Available from Iherb.com.
 

     But be advised that, once areas of the heart start generating A-Fib signals, it is often very hard to turn them off again. Vitamins and supplements may improve overall heart health and thereby help A-Fib, but they aren't generally considered "A-Fib specific" like some medications.
    (The author hopes to expand this list as more info becomes available and welcomes input and tips from readers. Go to Feedback. See also 11 strategies to prevent Lone Atrial Fibrillation by Dr. Lam.)

    Beware of the "natural" products Flemetron and Rillical. They may be scams. See: http://www.moh.govt.nz/moh.nsf/0/22459AF3D41CA288CC257676007E651F
http://onesickmother.typepad.com/my_weblog/2009/07/solutions-by-nature-scam.html

    Here are other possible remedies for A-Fib.
    1. Homeopathic remedies. Diane Willis writes that she took Unda #8¹⁵² and #248¹⁵³ 5 drops 5X a day. Her A-Fib stopped within 24 hours after homeopathic treatment.
    Diane adds, "Homeopathic doctors never prescribe on a "one size fits all" basis. They muscle-test to arrive at the right medications and dosages."
    Diane also is being treated by a Chiropractor, is on a "raw" diet, and is involved in the spiritual healing community. She isn't sure the Unda remedies were the one thing that stopped her A-Fib. "Although I personally feel that Unda was a leading contributor."
     Email: Diane Willis docflute (at) gerf.org (the "@" is written as "at" to prevent access from spam mailers).
    (The author knows very little about homeopathic remedies and welcomes input and explanations about how homeopathy works. The ingredients of Unda #8 and #248 are listed on the footnote reference pages.)

    2. Iron Overload or Lack of Iron (Anemia) may cause, trigger or influence A-Fib. Have your ferritin levels checked.

    3. Acupuncture, Acupressure. A 2010 study found acupuncture prevents arrhythmic recurrence after cardioversion in patients with persistent A-Fib. The article identified the acupuncture points to be stimulated. See Acupuncture Helps A-Fib---Specific Acupuncture Sites Identified. On the basis of this article, acupuncture could probably help Paroxysmal A-Fib as well.

    4. Chiropractic Adjustment, particularly for Vagal A-Fib. Bente Strong writes, "The Vagus nerve is central to digestive systems and the upper chambers of the heart. Keeping that area - the neck and thoracic (upper) region of the spine - open, aligned and flexible, clearly helps. I first discovered this after 3 days and nights on non-stop A-Fib, which went away for most of the next ten days after an adjustment. I now get a chiropractic adjustment every 2 weeks and frequently lie on my back across an exercise ball in order to stretch and adjust myself as best I can."
Bente Strong, email: bente_l(at)msn.com  (the "@" is written as "at" to prevent access from spam mailers)

    The following remedies may provide temporary relief from A-Fib attacks, but aren't likely to be a permanent cure, or they may not work at all for your A-Fib. Try them at your discretion.
    5. Moderate exercise. For some types of A-Fib, moderate exercise may sometimes bring you out of an A-Fib attack. For others, exercise may trigger or increase an A-Fib attack. (The author, when he had A-Fib, used to wear a heart rate monitor for runners---Polar, Acumen, Garmin, Nike, Cardiosport, Timex, etc.---when he jogged. But all too often the jogging would trigger or make the A-Fib worse, and he'd have to walk back home.)
    6. Deep breathing and holding one's breath while pressing down hard on the diaphragm.
    7. Putting cold compresses or ice on the back of one's neck.
    8. Laying down and trying to relax in a darkened room.
    9. A-Fib is sometimes triggered by body position---lying or leaning on the left side. Lying on one's back and relaxing the chest may help terminate A-Fib episodes which were triggered by lying on the left side, but won't help if the A-Fib episodes were not triggered by position.
    10. Putting one's head between one's legs and deep breathing.
    11. One person writes that eating something very spicy restores his sinus rhythm, though half the time the effect is temporary. Spicy food stimulates nerves in the stomach which in turn can influence atrial nerves. (Unfortunately in some people it may also provoke A-Fib.)
 

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

    In general, don't expect miracles from current medications. To date, the magic pill that will permanently cure your A-Fib probably doesn't exist.^{5 "}Drugs don't cure A-Fib but merely keep it at bay."¹⁶²

    The three main drug therapy treatment strategies are:
    1) to prevent blood clots and stroke by the use of blood thinners: (anticoagulants like warfarin, Coumadin, Jantoven; antiplatelets like Aspirin, Ecotrin, clopidogrel (Plavix), Ticlid); or Lovenox (an anticoagulant taken by injection), and Heparin (used in hospitalized patients. (Plavix and Ticlid are antiplatelet drugs like aspirin but they are not the same or interchangeable with aspirin. If your doctor prescribes Plavix or Ticlid, you should not substitute aspirin for them.)
    (Blood thinners don't actually thin the blood. Rather they inhibit the ability of substances in blood to form clots. They are more properly called "antithrombotic" or "anticloting medications.")
    Blood thinners reduce but do not totally eliminate the risk of stroke. Warfarin reduces the risk of stroke by 60% to 70% in A-Fib patients²⁹⁵ but is not an absolute guarantee one will never have an A-Fib stroke.
    To be effective warfarin (Coumadin) must be maintained at a certain level in the blood stream (INR---International Normalized Ratio between 2.0 and 3.0). Significantly above 3.0 you run the risk of having a hemorrhagic (bleeding) stroke. Below 2.0 you are more in danger of having an ischemic (clotting) stroke, the kind that most often occurs in A-Fib (85%⁵⁶).
     It is often difficult to maintain this INR, especially when you first start on warfarin. You may have to take sometimes weekly PT tests in your doctor's office till you get the warfarin dosage and INR right. "Even in the best clinical trials, only 70% of patients are able to keep warfarin within the desired therapeutic range."²²⁰ There are home use kits available for testing your own INR (for example, see http://www.PTINR.com}.
    Be aware that warfarin has a 1.8% annual risk of life-threatening bleeding.²⁹⁴ Warfarin may prevent an A-Fib (ischemic) stroke while somewhat increasing one's chances of a bleeding (hemorrhagic) stroke, particularly among the elderly.
    In general, aspirin is less effective than warfarin.⁴⁵ (See FAQs question #10 Which is Better---Warfarin or Aspirin?).
    You should also get tested for variations in the CYP2C9 and VKORC1 genes which influence how you respond to warfarin (Coumadin). If your doctor doesn't provide this testing, you may want to think about getting a second opinion. These tests could save you heart problems related to over- and under-dosing of warfarin.

Options to Blood Thinners
    (If you can't or don't want to take blood thinners, an option is to have a device installed to close off the Left Atrial Appendage where 90%-95% of A-fib strokes come from (Watchman or  Amplatzer in clinical trials). Then you would usually not need to be on blood thinners. For a partial list of doctors installing the Watchman device, see Doctors Installing the Watchman Device.)

    (Added 4/12/2011: Removing or closing off the Left Atrial Appendage (LAA) may affect how well the heart pumps and is of special concern to athletes and to those with heart pumping problems. In canine studies the LAA provided 17.2% of the whole left atrial volume of blood pumped.²⁵⁷ It's possible that removing or closing off the LAA may lead to heart pumping problems. The LAA is like a surge tank on a hot water heater. When the Mitral Valve closes, the LAA absorbs the surge of blood. When the LAA is amputated or closed off, this may cause increased pressure in the Pulmonary Veins and exercise intolerance. Few, if any, centers currently perform pre- and post-amputation exercise testing.)

    (Added 4/7/11) The FDA has approved a noose-like device that completely closes off the Left Atrial Appendage which dies and is no longer electrically active. See Lariat II.)

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

    2)  Another drug therapy strategy is to try to control the heart rate (ventricular beats), but leave the heart in A-Fib by what are called "rate control" drugs,¹⁰⁹ Rate control drugs aren't really a "treatment" for A-Fib. Though they slow the rate of the ventricles, they leave you in A-Fib. They may alleviate A-Fib symptoms, but do not address the primary risks of stroke and  death associated with A-Fib.²³⁵  Leaving patients in A-Fib overworks the heart and leads to remodeling and fibrosis which increase the risk of stroke.²⁶⁴ See Fibrosis Predicts Stroke Risk. Mellanie True-Hills of StopAfib.org asks, “Should we leave folks in A-Fib long term, especially the non-elderly? Between the risk of heart failure, and fibrosis from long-term remodeling increasing stroke risk, could staying in A-Fib long-term be a death sentence?”²⁶³ If your doctor only prescribes rate control meds for your A-Fib, you should question him/her and probably get a second opinion.     

    3) Another drug therapy treatment strategy is to try to stop the A-Fib and make your heart beat normally by what are called "antiarrhythmic" drugs.

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        RATE CONTROL MEDICATIONS
    Medications used for rate control can be categorized as:
    1.  Calcium-channel blockers prevent or slow the flow of calcium ions into smooth muscle cells such as the heart and blood vessels. Calcium-blockers are preferred if you have heart or lung disease. Common side effects are the heart beats too slowly and constipation.⁶²
    Calcium-channel blockers include: diltiazem (Cardizem, Tilazem, Cartia XT)  [the generic name of a medication is listed first, the Brand name is in parentheses] and verapamil (Calan, Isoptin). 
 
    2. Beta-blockers "block" the action of adrenaline on beta receptors in the cells of heart muscle. They slow down conduction through the heart and make the AV Node less sensitive to A-Fib impulses.
    Beta-blockers are better for active or young people, because exercise reduces the effectiveness of Digitalis and Calcium-channel blockers.
    Common side effects are: the heart beats too slowly, tiredness, and loss of sex-drive.^{62, 275} In many people, beta-blockers can reduce heart rate by 10 to 30 beats per minute.²⁸¹    
    Beta-blockers include: atenolol (Tenormin), metoprolol (Lopressor, Toprol-XL), esmolol HCI (Brevibloc), propranolol (Inderal), timolol, and pindolol and the newer drugs carvedilol (Coreg) and nebivolol (Bystolic).
    (A new study casts doubt on the effectiveness of most beta-blockers, because they promote fibrosis in the heart. Here is the actual medical language: Beta-blockers "undermine the structure and function of the heart...Blocking the beta-receptor alone promotes cardiac remodeling via growth of cardiac fibroblasts induced by alpha-adrenergic receptor signaling. The growth of fibroblasts in the heart further damages the integrity and function of the heart."²⁴⁷
    Carvedilol, however, targets both the beta- and alpha-adrenergic receptors on the heart muscle. "Beta-blockers (like carvedilol) which target both receptors "offer the most benefit to cardiac patients." A study in 2003 showed that carvedilol produced a greater survival rate than metoprolol.²⁴⁷ [Thanks to Janet Brown for calling our attention to this research.]
    Nebivolol seems to eliminate most of the common bad side effects of beta blockers by dilating blood vessels through the release of nitric oxide. But it also only blocks Beta 1 receptors. See nebivolol.)
 
    3. Cardiac Glycosides slow down and control the heart rate by blocking the electrical conduction between the atria and ventricles. The most widely prescribed Glycoside is digoxin (a Digitalis compound, brand names Lanoxin, Digitek), but medical authorities consider it the least effective.⁶ Digoxin is the most commonly used drug for rate control; but it is only effective at controlling heart rate at rest, when for example you are in the doctor's office.  But when you leave, your heart rate may go too high.²⁷⁴ Beta-blockers and calcium-channel blockers are generally more effective than Digoxin.²⁷⁴

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

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        "ANTIARRHYTHMIC" MEDICATIONS
    In general current "antiarrhythmic" (anti irregular heart rhythm) drugs aren't always effective and tend to have bad side effects such as pulmonary fibrosis and impaired liver function.^8,9,10,55  They also become less effective over time, with approximately half of the patients eventually developing resistance to them.⁵⁵ Up-to 50% of patients experience a recurrence of A-Fib after 1-year of antiarrhythmic treatment, and up-to 85% experience a recurrence after 2-years.¹⁵⁹ Many antiarrhythmic drugs require you to be hospitalized for 3-4 days when they are initially administered, in order to monitor you for bad side effects. Some antiarrhythmic meds can have a "pro-arrhythmic" effect on some people (people react differently to medications).
    According to Drs. Savelieva and Camm, "The plethora of antiarrhythmic drugs currently available for the treatment of A-Fib is a reflection that none is wholly satisfactory, each having limited efficacy combined with poor safety and tolerability."²⁴⁴

Types of Antiarrhythmic drugs
    Antiarrhythmic drugs are grouped in "classes" according to how they work.
    1. Class I are Sodium Channel Blockers which decrease the speed of electrical conduction in the heart muscle.
    2. Class II are Beta-Adrenergic or Beta-Blockers which slow down conduction through the heart and make the AV node less sensitive to A-Fib impulses.
    3. Class III are Potassium Channel Blockers which slow nerve impulses in the heart.
    4. Class IV are Calcium Channel Blockers which prevent or slow the flow of calcium ions into smooth muscle cells such as the heart. This impedes muscle cell contraction, thereby allowing blood vessels to expand and carry more blood and oxygen to tissues.

    Here is a list of the more commonly used antiarrhythmic drugs, based on an article by Dr. R. Falk of the Boston University School of Medicine:¹¹
      Procainamide (Procan SR, Promine, Pronestyl, Procanbid): Slows nerve impulses in the heart and reduces the sensitivity of heart tissue. Not FDA approved for A-Fib. Long-term use associated with lupus. Generally not used as a first-time drug because of bad side effects. Less effective against A-Fib than the other Class 1A drugs Quinidine and Disopyramide.²⁴ (Class 1A drug)
    Quinidine (Quinaglute, Quinidine Glaconate, Quinidex): FDA approved for A-Fib but risk of death increases during long-term use. Generally not used as a first-time drug because of bad side effects such as increasing the heart rate and impairing the heart's pumping efficiency. (Class 1A drug)
    Disopyramide (Norpace): Not FDA approved for A-Fib. Strong negative inotropic effect (heart muscle contractions weakened). Generally not used as a first-time drug. Good for patients with nocturnal or post-prandial (after meals) A-Fib.²⁷ (Class 1A drug)
    Flecainide (Tambocor): Slows nerve impulses in the heart and makes the heart tissue less sensitive. Approved only for paroxysmal (occasional) A-Fib with structurally normal heart. Normally the first drug tried on otherwise healthy patients with new A-Fib. Not recommended after a heart attack or if you have structural heart disease. (Class 1C drug)
    Propafenone (Rythmol and the newer version Rythmol SR): Same limitations as flecainide. (Class 1C drug)
    Sotalol (Betapace):  Not recommended (conversion from A-Fib to normal rhythm rate is low). (Class II and class III drug)
     Dofetilide (Tikosyn): FDA-approved for conversion and maintenance. (Class III drug)
    Amiodarone (Cordarone): Not FDA-approved for A-Fib. Moderately effective for conversion from A-Fib to normal rhythm, but onset is slow. Good rate slowing in A-Fib. This is usually the last drug tried on patients because of its toxic side effects particularly in the lungs, liver and thyroid. (Class III drug but it also blocks Sodium Channels like a Class I drug.)
     Dronedarone (Multaq): FDA approved in 2009. Chemically similar to amiodarone. While not as effective as amiodarone, it has less toxic side effects. See Dronedarone Safe in ATHENA Clinical Trials. Not for patients with severe heart failure.
    Ibutilide (Corvert): Not for patients with low blood potassium, a prolonged QT interval (slow heart beat), or torsade de pointes (very irregular, fast ventricular heart beats). Usually given intravenously. Effective in electrical cardioversion. Often used in place of Electrocardioversion (33% to 49% success rate) and is generally more effective in cases of Atrial Flutter than in A-Fib.¹⁰⁸ (Class III drug)

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

Xanax (alprazolam)  
    Sally writes that her A-Fib comes on at night and is very severe, preventing her form sleeping. "I get up and take Xanax .05 mg, and within 15 minutes or so, the A-Fib stops. And I can go to sleep." Xanax does seem to have beta-blocker properties, though it is primarily used to help panic attacks. See Xanax story. But be advised that Xanax is a controlled substance and might be addictive. (The author isn't aware of this use of Xanax for A-Fib and welcomes comments on this subject.)
    John Davis, who has Chronic A-Fib, writes that Xanax 0.5 mg lowers his heart rate to normal. Xanax has "saved my life, or maybe my sanity. IT REALLY WORKS."
John Davis
Email: davis2777(at)roadrunner.com (When typing this email address, substitute an "@" for the "(at)"---this substitution is necessary to prevent automatic search engines from sending spam to this email address.)
 
"PILL-IN-THE-POCKET" TREATMENT
    Another treatment approach for A-Fib is to take an antiarrhythmic med at the time of an A-Fib attack.
    For example, one person writes that he takes 100 mg of flecainide three times at intervals of twenty minutes when he has an A-Fib attack. This often shortens the time of an A-Fib attack. "It (the Pill-In-The-Pocket treatment) has changed my life in that it reduces my time in A-Fib to usually a couple of hours as opposed to between 12 to 36 hours. It allows me to recover completely in a lot quicker time, because my heart hasn't been going crazy for a day or more. And it also allows me to remain out of hospital, which has been fantastic." ( Leon, E-mail: sandman_oz (at) yahoo.com)
    Another person writes she would take Rythmol 300 mg and Inderal 20 mg, wait three hours, then take Inderal 20 mg, wait three hours, then again start the Rythmol 300 mg and Inderal 20 mg, etc. Although she daily took a 325 mg coated aspirin, during a bout of A-Fib she would also chew an 81 mg baby aspirin. (Marilyn, E-mail: nmshook (at) sbcglobal.net)
    (Leon and Marilyn were both later cured of A-Fib by Pulmonary Vein Ablations. You can read their stories at: TWO DIFFERENT "PILL-IN-THE-POCKET" APPROACHES---BOTH TURN TO CATHETER ABLATION FOR A CURE)
    Another treatment strategy is to take lower doses of an antiarrhythmic med on a regular basis, then take a higher dose during an A-Fib attack. Reg writes he takes 300 mg of flecainide, and 2 hours later goes back into SR. He normally is on a loading dose of flecainide 100 mg in the morning and 50 mg in the afternoon. (Email: r.j.tooth (at) shu.ac.uk. The "@" is written as "at" to prevent access by automated spam lists.)
    Will writes that he takes Rhythmol SR 325 regularly. If he gets a break-through event of A-Fib, he takes 600 propafenone, immediate release. "This always gets me back in Sinus Rhythm, usually in 90 minutes."
    At best, the Pill-In-The-Pocket treatment is a stop gap measure rather than a "cure" of A-Fib. (See also in the FAQs section "Is the "Pill-In-The-Pocket" treatment a cure for A-Fib? When should it be used?")
   

CHEMICAL CARDIOVERSION
    Chemical cardioversion is usually done in a hospital. Some combination of the above meds are administered intravenously, such as Cardizem, verapamil, ibutilide, or adenosine (a class V antiarrhythmic agent). Doctors monitor you closely for adverse side effects. Chemical cardioversion is often done in combination with Electrical Cardioversion described below.

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ELECTRICAL CARDIOVERSION
    Electrical Cardioversion is a medical term for giving your heart a shock with a defibrillator to synchronize it, to make it beat regularly (in normal sinus rhythm). It is often used in combination with Chemical Cardioversion.
    During Electrical Cardioversion you are anesthetized and are unconscious when you receive the shock. The shock causes signal producing areas of your heart to discharge all at once. This stops all electrical activity in your heart momentarily, hopefully allowing your normal heart rhythm to take over.
   
     Electrical Cardioversion seems to have the best chance of success in recent onset A-Fib. If your A-Fib just started, It may be a momentary aberration that an Electrical Cardioversion may correct.
    Electrical Cardioversion is considered low risk, but it does have a high risk of forming clots and causing stroke,¹⁴ which is why it is important to be taking anticoagulants like warfarin (Coumadin) both before the treatment and in the three to four weeks following treatment.^38,39 What doctors aim for is an INR (International Normalized Ratio) of warfarin in your blood that is between 2.0 and 3.0. (An Electrical cardioversion "stuns" your heart and your Left Arial Appendage where most A-Fib clots occur. Clots may form in the LAA while it is stunned and not beating.) You may have to have your blood tested weekly till your doctor determines you are in this range.
    If your A-Fib is so irregular and rapid that it is life threatening, you may be rushed to an Emergency room and be given the anticoagulant Heparin intravenously before your electrical cardioversion.
    Electrical Cardioversion, often combined with Chemical Cardioversion, is considered a standard, routine, low risk treatment option, particularly for recent onset A-Fib patients. However, sometimes after electrical cardioversion, your A-Fib comes right back. "50 to 75 percent of patients eventually develop Atrial Fibrillation again."³²
    Electrical Cardioversion is a shock to the body and requires general anesthesia. It's like a mini electrocution. (The Defibrillator paddles, for example, can leave burn marks on the chest.)
         People with A-Fib often ask, "How often can I be Electrical Cardioverted? Does it ever become counterproductive or dangerous?" Right now we just don't know the answer to this question. (Former Senator and NBA basketball player Bill Bradley had three successful Electrical Cardioversions from 1996-1998 without any apparent ill effects.¹¹² The author has heard of an A-Fib patient who received an Electrical Cardioversion once a month for a year without any apparent problems.) 
    See http://www.youtube.com/watch?v=-jkhQ5Tl2fs for a video about electrical cardioversion. Watch also http://www.youtube.com/watch?v=dC_i8zuclmQ for a more detailed description with excellent graphics.
    To watch an actual Electrical Cardioversion, go to http://www.youtube.com/watch?v=2nsN0vdXZuY&feature=fvw. But be advised, this video is a bit disturbing. (Thanks to Erdösi Béla for  alerting us to these sites.)
    Don’t be frightened by this video or others you may see on YouTube, the internet, and medical dramas on TV. It may look and sound traumatic, but Electrical Cardioversion is in fact non-invasive and is one of the easiest and safest short term treatments available for A-Fib.
    See also in the Personal Experiences section a story of someone who was accidentally awake during an electrical cardioversion. According to Kris, the shock is relatively mild compared to what you often see portrayed in medical dramas on TV.

ABLATION OR MODIFICATION OF THE ATRIOVENTRICULAR (AV) NODE AND IMPLANTING A PACEMAKER
    From a patient's point of view, this is a procedure of last resort. Each heartbeat normally starts in the right atrium where a specialized group of cells called the sinus node generates an electrical signal that travels down a single electrical road (the Atrioventricular [AV] Node) that connects the atria to the ventricles below. By ablating or eliminating this AV Node, your Atrial Fibrillation signals can't get to the ventricles which does stop your heart from racing. But for your heart to beat at all or at the proper rate, you must have a permanent pacemaker implanted in your heart for the rest of your life.
    An AV Node ablation is irreversible. What's worse, you still have A-Fib and have to forever take anticoagulants to prevent stroke. Also, patients with Paroxysmal (occasional) A-Fib often develop permanent A-Fib after an AV Node Ablation.⁷⁸ In addition, when you eliminate the AV Node, there is a risk of sudden death because of the ventricles beating too fast.¹⁵ Another factor to be aware of is A-Fib over time may decrease mental abilities and lead to dementia⁹⁸ (See A-Fib Decreases Mental Abilities.) (Biventricular pacing is generally preferred over uni-ventricular pacing which potentially can worsen or even cause heart failure by one ventricle beating out of sync with the other.)
    If you have a bad Sinus Node and would need a pacemaker anyway, this procedure might work for you.
    But an AV Node Ablation and Pacemaker does work. Patients report an improved quality of life (being able to golf 18 holes) than when A-Fib made their heart race and they were in symptomatic A-Fib.

THE MAZE AND MINI-MAZE SURGICAL OPERATIONS 
    In the Cox Maze open heart operation the surgeon makes numerous incisions in your atria. This "maze" of incisions divides your atria into electrically isolated segments, thereby blocking the electrical impulses that cause A-Fib from spreading throughout the heart. The atria continue to be activated by a regular signal from the sinus node. The left atrial appendage is usually removed during this operation. Dr. Cox developed a successor to the Cox Maze III called a "Radial Maze." In a later version of the operation, the Cox Maze IV, most of the "cut and sew" incisions are replaced with linear ablation lesions created either with radiofrequency energy or cryothermy (freezing).^{160, 293} Access to the heart on pulmonary bypass can be through the sternum (breast bone) or through incisions in the chest. If access is through the chest, Dr. Damiano, Jr. calls it a Minimally Invasive Cox Maze IV.  
    The Maze operation does work and has a high success rate ("approximately 75% at two years"²⁷¹; but it hasn't been used often because of the risks of open heart surgery, the danger of bleeding from the incisions, the pain, discomfort and prolonged convalescence from the operation, and the resulting reduced atrial function due to the incisions/lesions. (Voltage mapping of post-Maze patients may show that their left atrium has reduced or is entirely devoid of electrical activity because of the extensive scarring.) According to Surgeon A. Mark Gillinov of the Cleveland Clinic, having the Maze surgery alone generally should be done only after other therapies have been tried.²⁶⁰
    However, if you have to undergo open heart surgery for another heart problem, you may want to go to a heart center that can perform the Maze operation at the same time. But if you have a left atrium larger than 6.0 cm or if you've been in A-Fib for over five years, the long term success of the "Cut and Sew" Maze operation is under 80%.²³⁷

Mini-Maze
    In newer maze operations (such as the Wolf Mini-Maze or Saltman Microwave Mini-Maze) surgeons do not crack open the breastbone and stop the heart, but instead make small incisions in the chest to access the heart. They use tiny video cameras and even robotics to make the maze incisions. (See Advances in Surgical Therapy for A-Fib for a more in depth discussion of surgery for A-Fib.) (See also PROS AND CONS OF THE MINI MAZE OPERATIONS.) (See also the new Hybrid Ablation and Convergent Ablation where Surgeons and EPs work together sequentially on the same patient.)
    In the Saltman "thoracoscopic microwave ablation," the surgeons do not crack open the breastbone and stop the heart while putting the patient on a heart-lung machine as in the Cox Maze operation. Instead the surgeons cut keyhole-sized incisions on the sides of the chest to gain access to the heart. Using a tiny video camera the surgeons loop a catheter around the outside of the heart. Each lung is temporarily deflated in turn to allow the catheters to be threaded around the pulmonary veins. The ablation catheters create ±10 microwave lesions around the atrium that will scar and block the electrical impulses causing the irregular heart beat.⁶⁴
    Patients may ask if a Mini-Maze surgery is overkill for simple cases of Paroxysmal (occasional) A-Fib. Some surgeons would agree. In Surgeon Andy C. Kiser's practice, "when a patient has paroxysmal A-Fib and the left atrium is under 4.5-5.0 cm, we recommend percutaneous (through the skin) catheter ablation. In this population, simple pulmonary vein isolation may be effective in over 80% of patients."²³⁷ Surgeon James Edgerton does not normally perform surgery on Paroxysmal (Occasional) A-Fib patients. "I think they are very well treated with catheter ablation." (See surgeon James Edgerton's presentation on Hybrid Ablation.)

Mini-Maze Risks
    Mini-Maze surgeries "usually have significant risks compared with catheter-based electrophysiology procedures such as catheter ablation."²⁵⁵ Since 2008, there have been at least five U.S. patient deaths reported to an FDA database in A-Fib surgeries using AtriCure devices and one involving a Medtronic device. (That database doesn't prove that the devices caused the deaths.) ²⁶⁰ According to Thomas M. Burton of the Wall Street Journal, currently "there are no large studies comparing the safety of surgical ablation to that of other ways to treat A-Fib."²⁶⁰ 
    Mini-Maze-type surgeries can also be very painful, including ongoing numbness and phantom pain at chest access sites. In addition, deflating and re-inflating the lungs can be very difficult particularly for older people whose lungs are no longer very elastic. And "approximately 6% of patients may require a pacemaker."²⁶⁹
    In a very unscientific survey at one center, when patients were asked whether or not they would undergo a Mini-Maze surgery again, 50% said no way, 30% said it was a lot harder than they thought it would be, and 1 out of 5 said it was worth it.

Cutting Out, Stapling Shut or Closing off the Left Atrial Appendage
    One considered advantage of the Mini-Maze operations is that the Left Atrial Appendage (LAA) is closed off. Most A-Fib blood clots which cause stroke come from the Left Atrial Appendage. By closing off the Left Atrial Appendage, most but not all risk of stroke is eliminated even if you are still in A-Fib. 
    However, in a study by Surgeon Ralph Damiano, Jr. MD, "both suture exclusion and stapler exclusion had extraordinarily low success rates. In fact, none of the patients with stapler exclusion had successful closure...This study presents clear evidence of the inadequacy of these techniques."¹⁵⁰ According to Dr. Marc Gillinov of the Cleveland Clinic, staplers "can be hard to apply to the appendage and tend to leave a little cul-de-sac and also cause bleeding and tearing, so they are not particularly safe or effective."²⁹⁰ However, the AtriClip device (FDA approved June, 2010) makes it much easier for surgeons to close off the LAA during open heart surgery. The surgeon positions the rectangular-shaped device around the LAA and then closes it like a clamp. Blood no longer flows into and out of the Left Atrial Appendage.²⁹⁰ AtriCure has developed a version of the AtriClip which can be used in Mini-Maze surgery. (See FDA Approves AtriClip to Close Off Left Atrial Appendage.) If you are thinking of having a Cox Maze or Mini-Maze, ask the surgeon if they use the AtriClip to close off the Left Atrial Appendage.
Should the LAA be routinely cut out, stapled shut or closed off in all A-Fib patients?
    Reasons to Close Off the left Atrial Appendage 
    The rationale for closing off the LAA is that, in case the Mini-Maze fails which doesn't often happen, the patient is still protected from having an A-Fib stroke. 90%-95% of A-Fib strokes come from clots that originate in the LAA. In A-Fib, blood stagnates in the LAA and clots tend to form.  
    Another important consideration is that closing off the LAA, even if a person is no longer in A-Fib, may still prevent a stroke. The LAA is where most clots originate. If a surgeon is already working on the heart, why not close off the LAA and reduce the patient's chance of having a future stroke? (If they didn't close off the LAA, they could be sued if a patient later had a stroke, even if the patient was no longer in A-Fib.) Life (no stroke) is more important for most people than a possible reduced exercise intolerance.
    In the future even people without A-Fib may have their Left Atrial Appendage closed off if it prevents or reduces the risk of a stroke. There are currently a variety of devices, surgical and non-surgical, which can do this.
Functions of the Left Atrial Appendage
    Some question the need or benefit of removing the Left Atrial Appendage (LAA) if someone is no longer in A-Fib. For a patient made A-Fib free, would their heart function better or more normally if they still had their LAA?
    The LAA functions like a reservoir or decompression chamber or a surge tank on a hot water heater to prevent surges of blood in the left atrium when the mitral valve is closed.²⁸⁶ Without it there is increased pressure on the pulmonary veins and left atrium which might possibly lead to heart problems later.
    Cutting out or stapling shut the LAA also reduces the amount of blood pumped by the heart and may result in exercise intolerance for people with an active life style. (In dogs the LAA provides 17.2% volume of blood pumped.²⁵⁷⁾ This is usually not a problem for patients with Persistent (Chronic) A-Fib, whose LAA has stopped contracting along with the fibrillating atrium. Cutting out or stapling shut the LAA won't affect their cardiac output. But this may not be the case for patients with Paroxysmal A-Fib who still have large amounts of normal rhythm and whose LAA still functions normally. But would a non-functioning LAA return to normal when someone with, for example, longstanding persistent (Chronic) A-Fib is made A-Fib free?
    The author isn't aware of any Surgeons (or EPs) who do pre- and post-LAA closure measurements of exercise ability, heart pumping function, etc.
    (When doctors do a TEE [Transesophageal Echocardiogram] of the LAA of someone in A-Fib, the LAA doesn't move at all and blood does not move. Doctors refer to this as "SMOKE" which is shorthand for Spontaneous Echo Contrast. The blood not moving looks like smoke inside the LAA.)
    The LAA also has a high concentration of Atrial Natriuretic Factor (ANF) granules which help to reduce blood pressure.²⁸⁷ 

Mini-Maze Surgeries with Left Atrial Lesions
    Scarring in the heart permanently damages heart tissue and is usually avoided unless absolutely necessary. When RF ablation lines are made on the heart, the areas of scarred heart tissue are rendered electrically dead and fibrotic. (Imagine a red hot poker laid across your heart.) Circulation, nerve signal pathways, heart muscle fibers, transport function, etc. may be affected. This is irreversible heart damage. Non-contracting scar tissue replaces normal heart muscle. This may weaken the heart and may later contribute to congestive heart failure. Millions of heart patients today suffer from weak hearts due to heart muscle damage.
    These ablation burns are normally not a problem in the Pulmonary Vein areas which function as pipes into the left atrium, but may be a problem in areas of the left atrium more involved in heart function and contraction.
    Newer Mini-Maze surgeries, such as the Totally Thoracoscopic (TT) Maze and the Five-Box Thorascopic Maze Surgery are one-size-fits-all surgeries which create ablation lines/burns on the left atrium. But we don't know if this scarring is necessary or appropriate for all cases of A-Fib. 
    Patients should ask their surgeons if this scarring of the left atrium is necessary to fix their type of A-Fib. Would a Pulmonary Vein Ablation procedure, for example, fix their A-Fib without the added risks of heart surgery and permanent heart damage?

Mini-Maze Marketing: Profit Incentives
    Be advised that some hospitals, medical services, web sites, etc. may promote the Mini-Maze over catheter ablation, because current reimbursement rates are higher for surgery (currently around $15,000) than for catheter ablation. Mini-Maze-type surgeries represent a huge and growing market and an important income source for hospitals, surgeons, medical device companies, web sites, etc. 
    Some 25,000 patients underwent Mini-Maze-type surgeries in 2009. Surgical devices to treat A-Fib have sales of about $100 million a year.²⁶⁰
    Doctors may use medical devices for "off-label" treatments. But companies are only allowed to market them for the uses for which they have been FDA-approved. The idea behind this restriction is to limit the number of U.S. patients exposed to experimental, relatively untested treatments.
    For example, AtriCure, of West Chester, Ohio, in 2010 agreed to pay $3.8 million to resolve allegations it marketed its surgical ablation devices for the unapproved purpose of treating irregular heart beats (A-Fib). According to an article in Mass Device,

"The (U.S. Dept. of Justice [DOJ]) lawsuit accused AtriCure of offering kickbacks to induce surgeons and hospitals to use its inpatient cardiac ablation procedure rather than less expensive, outpatient alternatives (such as catheter ablation). The company was accused of promoting the spread between Medicare reimbursement rates for its procedure and the cost to hospitals, and doling out kickbacks including free equipment, discounts, free advertising, marketing, and referral services and training for surgeons on its procedure."²⁶¹
 

According to Jacqueline Bell of Law 360,

"The DOJ also alleged that AtriCure pushed heart surgery using the company's medical devices when less-invasive alternatives were appropriate, and suggested to hospitals how to pump up Medicare reimbursement claims for surgical procedures using the company's devices."²⁶²

AtriCure did not admit wrongdoing.
    Estech (Endoscopic Technologies), of San Ramon, California, agreed to pay $1.5 million to settle similar charges with the Justice Department, also without admitting wrongdoing.²⁶⁰

(Added Dec. 21, 2011.) AtriCure's Synergy Ablation System was recently approved by the FDA (December 16, 2011). The FDA approved the AtriCure system "in patients who have persistent or longstanding persistent Atrial Fibrillation and are also undergoing surgery for coronary artery bypass grafting or valve repair or replacement."³⁰¹

List of Surgeons Performing Cox-Maze and Mini-Maze Surgery
    For a partial list of Surgeons doing Cox-Maze and Mini-Maze operations, see Surgeons Performing Maze and Mini-Maze Operations.

 

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PERMANENT PACEMAKER THERAPY
    A pacemaker is a small device that sends electrical impulses to the heart muscle to maintain a regular heart rate. In general, pacemakers are not very effective for preventing A-Fib. Implanting a pacemaker seems to be most helpful if you have a slow heart rate as a result of taking A-Fib medications. Also, a pacemaker that paces the atria may prevent recurrence of A-Fib in up to 20% of patients.¹⁶ (But see Gold for a more critical appraisal of pacemaker therapy.) However, a pacemaker usually isn't implanted unless your heart rate is too slow¹⁶ or you have Sinus Node and/or Atrioventricular (AV) Node problems. But be advised that pacemakers tend to have bad effects over the long term, "...a long-term morbidity (is) associated with a pacemaker."⁸⁰
    (The author admits to not knowing much about pacemakers. Happily one of the A-Fib correspondents installs pacemakers and offers the following observations.)
    "I like to tell patients who receive pacemakers that, after a couple of months, they can have a VERY active, normal lifestyle.  All of the current pacers have a "rate responsive" mode, meaning they are designed specifically for activity. The more active you are, the faster the pacer goes. Three triathlon runners, and two NFL players have pacers. Most people forget they have a pacemaker.
    A recent trend is to implant the ventricular lead on the septum vs. the right ventricular apex, which gives better cardiac output and a more 'normal' heartbeat. You might want to ask your doctor about this possibility. Even if your doctor does not prefer this technique, he/she will be impressed that you did your homework.
    In addition, you always want a dual chamber pacer which will give better cardiac output. It will also attempt to synchronize between the atria and ventricles, unless the patient is in Chronic A-Fib. If the A-Fib is intermittent, the pacer will temporarily switch modes to VVIR (ventricular only pacing) during the A-Fib, and then back to normal DDDR (dual chamber) pacing when the A-Fib terminates. This is all done by the device memory/logic program.
    ("DDD" signifies a dual chamber pacer, capable of sensing and pacing in both the atrium and the ventricle)
    ("VVI" is ventricle only)
    ("AAI" is atrium only)
    ("R" signifies Rate Response, a programmable on/off feature which increases the pacing during activity)
    So, during A-Fib, the DDDR pacer will switch to VVIR and pace only the ventricle during the A-Fib."
   

IMPLANTABLE DEFIBRILLATOR
    Having a defibrillator implanted in your heart is, from the point of view of most patients, not a probable option. A defibrillator shock is painful, like being "kicked in the chest." Most people would rather have A-Fib than be shocked throughout the day and night. Also, it does not address the underlying problem or condition of your heart that causes your A-Fib.
    Our A-Fib pacemaker correspondent writes:
    "Defibrillators are far more complicated (than pacemakers). When people report getting a big shock (500-700 volts) from the unit, that was probably for V (ventricular) Fib, not A-Fib, if the unit is programmed properly. One good thing about the V-Fib is that it is usually (not always) proceeded by Ventricular Tachycardia, a much slower, organized rhythm that often responds to painless anti-tachycardia pacing. We will attempt anti-tachycardia overdrive pacing for several different patterns before we finally give up and go to the full output shock." (See also LIVING WITH A PACEMAKER/ICD)

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PULMONARY VEIN ABLATION (ISOLATION)
    Atrial Fibrillation is curable.³⁰⁰ Current Pulmonary Vein  Ablation (Isolation) (PVA(I) techniques are achieving success rates of 70%-85% in making Paroxysmal A-Fib patients A-Fib free with low risk.^{17,33,34,41,243,285} A successful PVI also reduces the threat of death by 50%.²⁸³ (Check with your particular heart center for its success rate.) "Curing" A-Fib is defined as restoring patients to normal sinus rhythm without dependence on any medications.⁴¹ (The other 15%-30%, though not "cured" of A-Fib, may be significantly improved after an ablation. They may have fewer or less intense attacks of A-Fib. Medications that didn't work before may now control the A-Fib. But for some there may not be any noticeable improvement at all.)
    Currently the FDA has approved Radio Frequency and CryoBalloon ablation catheters for the treatment of A-Fib. See FDA Approves First Ablation Catheter for A-Fib and  FDA APPROVES CRYOBALLOON ABLATION CATHETER

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

    During Pulmonary Vein Ablation a soft, thin, flexible, coated tube with an electrode at the tip is inserted through a large vein in your groin and moved into your heart. This catheter is directed to the precise location(s) in your heart that are producing your A-Fib. These points are burned off or isolated from your heart. (To see a news video of this procedure, go to http://newyork.cbslocal.com/2010/08/24/healthwatch-a-fib/). Doctors use Fluoroscopy, a special type of X-Ray, or other imaging systems to see inside the heart and map where A-Fib signals are coming from. (The catheter is about the width of the lead in a pencil, while the vein is about the size of your little finger.)
    This is a relatively new procedure. (The first journal published report of a successful catheter ablation for A-Fib in humans was done in 1994 in Bordeaux, France.²¹ The first published studies of Focal Ablation [Pulmonary Vein Ablation] within the Pulmonary Veins came from Bordeaux⁴⁷ and Taipei.⁴⁸) Currently, many heart centers in the U.S. are doing Pulmonary Vein Ablation of A-Fib on a regular basis. (For a partial list of these facilities, see Doctors/Facilities.)
    This is a relatively painless procedure, because there are no nerve endings in the smooth tissue of the heart and veins. However, someone recently wrote me that they felt a lot of pain from the ablation burns.
    If you are in A-Fib during the Catheter Ablation procedure, it's relatively easy for the doctors to determine where the A-Fib signals are coming from and to ablate (remove) them. However, if you have intermittent A-Fib (Paroxysmal A-Fib), it's harder to pinpoint exactly the source(s) of the A-Fib signals.
    The challenge for doctors is how to locate and eliminate A-Fib signals when the patient is not in A-Fib. Since research has shown that most A-Fib signals come from the openings (ostia) of the four Pulmonary Veins in the left atrium, one technique is to make Circular Radiofrequency (RF) Ablation lines around each pulmonary vein opening (called  "Circumferential Ablation" or "Pulmonary Vein Antrum Isolation" [PVAI]). This isolates the pulmonary veins from the rest of the heart and prevents any pulses from these veins from getting into the heart. However, it's difficult to make circular RF lesions and they aren't always successful. (A new technique of circular ablation uses a balloon catheter and cryo (freezing) energy to encircle the vein opening and make the circular lesions.²² Other energy sources such as laser and ultrasound balloon catheters are in development.)

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

Pulmonary Vein opening (ostium) showing A-Fib PV triggers. Muscular extensions of the left atrial tissue into the pulmonary veins may develop into focal PV triggers where premature atrial beats and A-Fib signals originate. These foci initiate A-Fib signals. Catheter Ablation at the left atrial-pulmonary vein junction electrically isolates the pulmonary veins, thereby trapping these A-Fib signals so that they can not excite the left atrium. (From http://www.washingtonhra.com/41.html  Dr. Pirooz Mofrad.)
   
    During an ablation procedure, after the Pulmonary Vein Potentials or PV Triggers are isolated, the doctor will try to induce A-Fib/Flutter by the use of drugs such as Isoproterenol. All too often other A-Fib Potentials or Trigger sites are found outside of the Pulmonary Veins. These have to be tracked down, mapped, and ablated/isolated. The goal is to eliminate all these sites so that A-Fib/Flutter can no longer be induced. (Thanks to Daniel Jachimczyk for this clarification.)

    Another procedure for isolating A-Fib signals is called "Anatomically Based Circumferential Pulmonary Vein Ablation" by Dr. Carlo Pappone of Milan, Italy who first developed this technique⁵⁸. It is also called "Left Atrial Ablation" by Dr. Fred Morady of the Un. of Michigan⁶⁰. Instead of concentrating on the Pulmonary Veins and Pulmonary Vein Potentials, the emphasis is on creating blocking lesions in the left atrium similar to "Circumferential" ablation described above. But instead of trying to make continuous, perfect linear lesions, a large diameter catheter at a high wattage is dropped and dragged to make the circular linear lesions. There may be gaps left in these lesions which may result in Atrial Flutter. But over time scar tissue usually closes these gaps (see Morady and Pappone). (At the 2008 Boston A-Fib Symposium Dr. Pappone's presentation showed nearly continuous, perfect linear lesions with very few gaps.)

    Another strategy recently approved by the FDA (December 2010) uses a Cryo (freezing) Balloon catheter to isolate the Pulmonary Veins. Typical RF catheters make circular ablation lines around pulmonary vein openings by point-by-point ablations which require significant operator skill and are time-consuming. But the CryoBalloon catheter creates  a circumferential lesion with a single application of freezing. The balloon inflates and is pressed up against the pulmonary vein opening. The balloon fills with coolant which makes the balloon stick to the PV opening until the tissue is ablated. In the clinical trials the CryoBalloon was faster, easier to use, and significantly safer than RF ablation.54a Barring unforeseen developments,  CryoBalloon catheter ablation will probably replace RF ablation for patients who only need standard PV isolation. Currently the CryoBalloon catheter is not suitable for making linear lesions that may be required  in patients with right or left atrial flutter or persistent A-Fib.54b  But the FDA-approved Cryo Freezor Max Catheter can be used to make linear lesions.
    To see an excellent animation of how the CryoBalloon works, go to  http://medgadget.com/2010/12/medtronic_brings_first_cryoballoon_ablation_system_to_us.html 
 
    Pulmonary Vein Ablation (Isolation) is considered safe²⁹⁹ and is a lower risk procedure than, for example, open heart surgery.³³ But it is not risk free. For a more in depth look at the actual risks involved, see Risks in the FAQs section.

PERMANENTLY A-FIB FREE?   
    Catheter Ablation (and the different Maze surgical operations) are currently the only strategies offering the hope of becoming A-Fib free permanently. But there is a problem with recurrence/reconduction after a "successful" ablation and surgery. Heart tissue is very hardy. Over time ablation scars can heal over and allow A-Fib signals to again disrupt the heart. Recent research indicates there is an approximately 7% chance of recurrence/reconnection each year out to five years. Since A-Fib ablation is a relatively new procedure, we don't have figures for longer than five years. (The author has been A-Fib free for 12 years after a successful catheter ablation.) For a detailed discussion, see RECURRENCE/RECONDUCTION/DURABILITY OF CATHETER ABLATIONS

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

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

1. "My A-Fib just started."
    
2. "My A-Fib is occasional (Paroxysmal) with no or mild symptoms (sometimes referred to as "silent' A-Fib)."
    
3. "I have infrequent, short episodes of symptomatic A-Fib."
    
4. "I have Paroxysmal (occasional) A-Fib but am in good health overall."
    
5. "I have Paroxysmal (occasional) A-Fib but also have serious heart and/or other health problems."
    
6. "My A-Fib is Persistent or Chronic (all-the-time)."
    
7. "I have Persistent or Chronic (all-the-time) A-Fib but no symptoms ('silent') A-Fib."
    
8. "I have A-Fib but am allergic to Coumadin, Heparin, Lovenox and most blood thinners. I'm also very overweight. And I've already had one stroke."
    
9. "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 cardioversion, your heart won't go back into A-Fib. But don't delay. This treatment seems to work best in cases of recent onset A-Fib.
    
2. "I have occasional (Paroxysmal) A-Fib with no or mild symptoms (sometimes referred to as "silent' A-Fib)." Doctors may have discovered you had A-Fib during a routine examination, but you weren't aware of anything wrong and feel generally OK.
       Since you've probably had A-Fib for a while, an Electrical Cardioversion may not have as good a chance of getting you back into normal sinus rhythm. But it might be worth trying.
       Another option might be to just live with the A-Fib, since it doesn't seem to affect you very much. You still need to talk with your doctor about whether or not you should be on blood thinners, since with "silent" A-Fib you are at risk of an A-Fib stroke. Your doctor may also prescribe Rate Control medications to make sure your heart doesn't beat too fast.
       However, this option of just living with A-Fib may eventually cause you problems. Over time A-Fib tends to stretch and weaken the heart often leading to other heart problems and heart failure.⁷⁷ An enlarged atrium (approximately over 55 mm) may limit your options. Some centers won't accept patients for a PVA(I) procedure if they have an enlarged heart, because the heart walls have been stretched thin and are easily perforated and burnt through by an RF ablation catheter. Also, A-Fib over time may lead to decreased mental abilities and even dementia, because blood isn't being pumped properly to the brain and other organs (see A-FIB DECREASES MENTAL ABILITIES).
       If you choose the option of just living with your A-Fib, 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 out for bad side effects. There is a fine line between giving your body time to adjust to the antiarrhythmic med, and recognizing that the medication is causing you unacceptable side effects. Some people have had success with flecainide (brand name Tambocor) or the newer meds dofetilide (Tikosyn) and Rhythmol SR.
       Because your symptoms are infrequent, you may have a simpler, more easily fixed type of A-Fib; i.e., your A-Fib may come from only one or two spots in the heart which a Pulmonary Vein Ablation (Isolation) has a good chance of curing. However, many doctors and medical centers are hesitant to perform a PVA(I) on someone with relatively infrequent A-Fib episodes.
       (Editor's Suggestion: If you are on an antiarrhythmic med and are going to have a Pulmonary Vein Ablation (Isolation) procedure, you may want to talk with your doctor about stopping the antiarrhythmic med at least four days before your ablation. Otherwise the antiarrhythmic med may mask A-Fib signal sources in your heart. [Thanks to Ian Betts for this observation.]
    
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 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 your heart stay in normal sinus rhythm.
       (Editor's Suggestion: If you are on an antiarrhythmic med and are going to have a Pulmonary Vein Ablation (Isolation) procedure, you may want to talk with your doctor about stopping the antiarrhythmic med at least four days before your ablation. Otherwise the antiarrhythmic med may mask A-Fib sources in your heart. [Thanks to Ian Betts for this observation.]
   
    
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).
       If your heart problems require surgery, you may want to consider going to a surgeon who can perform a Maze operation at the same time.
    
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 Persistent or Chronic (all-the-time) A-Fib but no symptoms ('silent') A-Fib. "
       You may want to consider just learning to live with the A-Fib. You will have to be on blood thinners or have a Watchman device installed to keep from having an A-Fib stroke. You will probably have to take rate control meds to keep your heart from beating too fast. Your heart isn't pumping out properly, but you can compensate to some extent by exercise. You may be able to lead a close-to-normal life in silent Chronic A-Fib. It's hard to justify the effort and risk necessary to fix Chronic A-Fib if you have no A-Fib symptoms.
       Chronic A-Fib is harder to fix and often requires at least two ablations. An unintended consequence of a successful ablation for Chronic A-Fib is your A-Fib may be improved so that you are only Paroxysmal (occasional). But Paroxysmal A-Fib may be more debilitating and troublesome than being in Chronic A-Fib. At least in Chronic A-Fib you don't have to worry about an A-Fib attack.
       A Cox Radial Maze to fix Chronic A-Fib is open heart surgery which is very traumatic and risky. It's hard to justify open heart surgery if you're feeling OK. 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.
       Another factor to consider is your age. If you're 40 years old, it's probably worth the effort to get your silent Chronic A-Fib fixed. Chronic A-Fib over time will probably damage your heart, brain, and other organs. But if you're in your 70s, you can probably live the rest of your life in a satisfactory, fulfilling manner even with silent Chronic A-Fib.
       However, having had A-Fib, the author knows how wonderful it is to be in normal sinus rhythm. Even though you have silent Chronic A-Fib and in general feel OK, you may want and need to get rid of your Chronic A-Fib. Most doctors understand this need to have a heart that beats normally and will work with you, as long as you understand the risks and challenges. See the options under I Have Chronic A-Fib.
    
8. "I have A-Fib but am allergic to Coumadin, Heparin, Lovenox and most blood thinners. I'm also very overweight. And I've already had one stroke."
       You might be a good candidate for a Mini-Maze operation, since you don't have to be on blood thinners during and after a Mini-Maze operation.
       A Mini-Maze is possibly a better option if you have had a stroke or are more in danger of having a stroke during a catheter ablation. 
       The Mini-Maze is sometimes a better choice if you are "morbidly obese." With current fluoroscopic imaging systems used in catheter ablation, it's more difficult to see a clear image of the heart if someone is overweight. And greater doses of radiation often have to be used.²⁰⁷
        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 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 isolate all areas of the heart where A-Fib signals may originate. If you have a simple case of recent onset A-Fib that requires only the isolation of the Pulmonary Vein openings, the Mini Maze operation may work for you. But anything more complicated is questionable. Currently surgeons don't have the ability to map inside the heart to identify sites where A-Fib originates. For example, patients with long-standing persistent (complicated) A-Fib tend to have relatively poor results. One study cites a 46.2% success rate after three months.²⁴⁶
       One considered advantage of the Mini Maze operations is that the Left Atrial Appendage is cut out and/or stapled shut. Most A-Fib blood clots which cause stroke come from the Left Atrial Appendage. By cutting out or closing off the Left Atrial Appendage, most but not all risk of stroke is eliminated even if you are still in A-Fib. However, the success rate for closing off the LAA by surgery currently isn't anywhere near 100%. In a study by  Dr. Damiano, Jr., "both suture exclusion and stapler exclusion had extraordinarily low success rates. In fact, none of the patients with stapler exclusion had successful closure...This study presents clear evidence of the inadequacy of these techniques."¹⁵⁰ (The Watchman Device has a better success rate for closing off the Left Arial Appendage and involves less risk.)
       (You may want to read in the Personal Experiences section a description of THE SALTMAN MICROWAVE MINI MAZE OPERATION [as of 2009 the Saltman Microwave Mini Maze operation isn't currently available].)
       A Mini-Maze is considered overkill for simple cases of Paroxysmal (occasional) A-Fib. In Surgeon Andy C. Kiser's practice, "When a patient has paroxysmal A-Fib and the left atrium is under 4.5-5.0 cm, we recommend percutaneous catheter ablation. In this population, simple pulmonary vein isolation may be effective in over 80% of patients."²³⁷ Surgeon James Edgerton does not normally operate on Paroxysmal (Occasional) A-Fib patients. "I think they are very well treated with catheter ablation." See Dr. Edgerton's presentation on Hybrid Ablation.
       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. (Added 4/28/11: But see the new Hybrid and Convergent Ablation operations where surgeons and EPs do work together.) 
       (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 your left atrium is larger than 6.0 cm or you've been in A-Fib for over five years, the long term success of the "Cut and Sew" Maze operation is under 80%.²³⁷  See Advances in Surgical Therapy for A-Fib.
    
9. "I've had two failed left atrium ablations and have tried many different medications."
       You can go for a third left atrium ablation, but you need to go to the best, most experienced A-Fib doctors you can find. You are a special case and deserve special treatment.
       The Mini Maze operations probably wouldn't work for you because of the reasons mentioned above (see Pros and Cons of the Mini Maze operations.)
       A Cox Radial Maze operation may work for you. (Added 12/20/10: There is a new type of Mini-Maze operation called the "Five-Box Thorascopic Maze Surgery" or Total Thorascopic Maze (TTM) which was developed by Dr. John Sirak of the Ohio State University. According to Dr. Sirak's web site, it has a "cure rate in excess of 95%." [Author's Note: This Mini-Maze surgery may be an alternative to the full Cox (Radial) Maze surgery for A-Fib.]
   http://www.ohioafib.com/maze-surgery/)
       A last option is Ablation or Modification of the Atrioventricular (AV) Node and Implanting a Pacemaker. Though you are still in A-Fib and have to continue taking blood thinners and probably rate control meds, your ventricles are no longer affected by A-Fib. In general people report a better quality of life than when A-Fib made their heart race.
   
       

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