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If you've visited A-Fib.com before, this section will list any changes or additions to A-Fib.com by date, the most recent topic first.

JANUARY 31, 2012
Septum Opening Plugged? You Can Still Have a Catheter Ablation to Fix your A-Fib.
    According to conventional A-Fib practice, if someone had a closure device installed to plug a hole in the septum, then they couldn't have a catheter ablation. It would be difficult to get the catheter through the septum wall since the plug occupied part of the septum wall. The plugging device would block the trans-septal puncture needed to get to the left atrium.
    But a recent study at the Texas Cardiac Arrhythmia Center in Austin, Texas by doctors Pasquale Santangeli and Luigi Di Biase demonstrated that it is feasible and safe to do a catheter ablation on patients with a septal occlusion device (Amplatzer, CardioSEAL).
   in most cases (35) the doctors were able to puncture the septum in an area not covered by the closure device. In four cases the doctors were able to puncture through the closure device itself using normal procedures and instruments, though this did take longer and involved more fluoroscopy time.

A-Fib Patients with a Septal Closure Device Often Need Aggressive Treatment
The patients in this study all had A-Fib before the septum plug was installed. They all progressed to highly symptomatic A-Fib and were not helped by drugs. Over a period of at least four years 11 patients progressed to persistent A-Fib. Five with persistent A-Fib progressed to permanent long-standing A-Fib. These patients obviously needed an aggressive treatment. (A septum opening between the left and right atria can lead to clot formation and stroke {see Tedy Bruschi]. Closing off this septal defect helps prevent stroke and is considered to decrease the risk of developing A-Fib. But if one already has A-Fib, closing off the septal defect opening doesn't halt the progression of A-Fib.)

Catheter Ablation Successful through a Septal Closure Device
After a mean follow-up of around 14 months, 77% were free of A-Fib and atrial tachycardia (this is a high success rate considering that 67% of the patients had persistent or long-standing persistent A-Fib which is more difficult to ablate). There were no significant differences in outcome between those who had transseptal puncture or puncture through the closure device. No patients at three and six months intervals had "interatrial shunt;" i.e., the puncture holes all closed up by themselves.
The doctors concluded that catheter ablation in patients with the septal closure device was "feasible, safe and effective." They added, "Transseptal puncture can easily be performed in a portion of the native septum not covered by the device in the majority of patients. Direct access through the device is also feasible and safe but requires significantly longer time."

eDITOR'S COMMENTS:
    Closing a septal opening decreases the risk of stroke and possibly also of developing A-Fib. But if someone already has A-Fib, closing this septal defect doesn't halt the progression of A-Fib. These patients often need aggressive treatment such as surgery (Cox-Maze or Mini Maze).
    If you have a closure or plug device installed in your septum, you now have another option besides surgery to fix your A-Fib. But be aware that most catheter ablation centers will still be reluctant to do a PVI in your case and will likely refer you to a surgeon. Even though PVIs in patients with septal closure devices can be "easily performed," It may take a while for the techniques and experiences of the Texas Cardiac Arrhythmia Center to become common practice in other catheter ablation centers. Right now you may need to go to Texas or to another center with experience doing PVIs on patients with septal closure devices.
    If you have a septal closure device installed, be sure and ask the doctor(s) you are working with if they have experience in ablating patients with septal closure devices.

Santangeli, P, Di Biase, L, et al. "Transseptal access and atrial fibrillation ablation guided by intracardiac echocardiography in patients with atrial septal closure devices." Heart Rhythm. 2011 Nov;8(11):1669-75. Epub 2011 Jun 22.

JANUARY 28, 2012 Report from the 2012 Boston A-Fib Symposium

GENETICS OF A-FIB

Genetic research in A-Fib, though in its preliminary stages, has the potential to be a game changer for patients with A-Fib.
Dr. Patrick Ellinor of Mass General, Boston gave a presentation on the “Genetics of A-Fib: How Will We Translate GWAS Findings to Clinical Practice?”

“If you have any immediate family with A-Fib, you have a 40% increased risk of developing A-Fib yourself. And the younger that someone in your family gets A-Fib, the more likely you are to have A-Fib.”

If someone has A-Fib, should all their immediate family members be screened for A-Fib? Since in the US alone over three million people have A-Fib, it isn’t possible or practical to screen all family members for A-Fib. And even if we could screen everyone, we don’t yet have the means to prevent A-Fib from developing or even to identify patients with pre-A-Fib.

EDITOR'S COMMENTS:
If anyone in your immediate family has A-Fib, you are very likely to develop A-Fib yourself. You have to be more aware and vigilant than the average person.
If, for example, you feel palpitations or a racing heart rate, take it very seriously. Don’t hesitate or delay in going to an Electrophysiologist (EP) to have yourself checked out. Make sure you tell your GP or Cardiologist that your relative has A-Fib.

Dr. Ellinor identified the specific genetic chromosomes currently found to be associated with A-Fib:
1q21

People with the 4q25 genetic variant chromosome are six times more likely to develop A-Fib.

But current research has only revealed “associations.” Further research is needed to determine:

1. Are these chromosomes associated with and/or do they cause an increased risk of A-Fib stroke, heart failure and death?

2. Are these genetic variants associated with or do they indicate that a certain treatment should be used or that a certain outcome is more likely?

4. How do these genetic variants affect what types of arrhythmia develop? Do Paroxysmal A-Fib, Permanent A-Fib, or A-Flutter have different genetic profiles?

5. And most importantly, how do these genetic variants work? What Is the mechanism behind them?

“Right now all we have is an association.” “We don’t have a fundamental understanding as to how the variants themselves lead to the (A-Fib) disease.”

If you have A-Fib, you must warn all your immediate family members that they have a good chance of getting it also. Even though we don’t know yet how to definitively prevent A-Fib, there are some precautions your family members can take:

2. Avoid antihistamines and anything that can stimulate or trigger A-Fib. (see A-Fib Triggers) (This doesn’t necessarily include coffee. Some research indicates coffee may prevent A-Fib.)

3. Be more attentive to overall health. Obesity, for example, is often a contributing factor to A-Fib.

4. Check for deficiencies in essential minerals (electrolytes) like magnesium or potassium? Are calcium levels too high (which may be a trigger for A-Fib)?

There is a tendency in all of us to not tell others if we are ill, perhaps because we perceive it as somewhat humiliating and a weakness in ourselves. But no one should be ashamed of having A-Fib. Most likely it isn’t anything we brought on ourselves. It’s genetic! It’s nobody’s fault!

We are not being fair to our family members by not telling them about our A-Fib. Don’t just mention it in passing. Sit down with them and tell them what A-Fib is like, and that they are at risk. If you love your family, you owe it to them. This applies particularly to your brothers and sisters with whom you may have a loving but somewhat competitive relationship. Anyone in your immediate family must be warned.

OBESITY, SLEEP APNEA AND A-FIB

Dr. Stanley Nattel from the University of Montréal Canada made an insightful scientific research presentation on “Obesity and Obstructive Apnea – Mechanisms of AF Promotion in Experimental Models” at the 2012 Boston A-Fib Symposium. It’s well known that obesity and obstructive sleep apnea increase the risk of developing A-Fib. But what isn't known is what specific mechanisms promote A-Fib, such as hypoxia, autonomic imbalance, left ventricular dysfunction, intravascular volume change, and/or strongly negative intrathoraic pressures.

In a brilliant experiment Dr. Nattel studied rats bred to be fat. These Zucker obese rats weighed almost twice as much as the normal lean rats in the experiment. Both the obese and lean rats were subjected to either obstructive sleep apnea or non-obstructive sleep apnea, versus a control group of both lean and obese rats not subjected to apnea. The obstructive sleep apnea generated a strong negative chest pressure caused by forced inhalation against the closed airway, while in the non-obstructive sleep apnea group the rats could still get some air through a side port. He then induced A-Fib by pacing in all the rats.

No rats had inducible A-Fib in the absence of apnea, indicating that, at least in this experiment, obesity by itself did not result in inducible A-Fib. Also, it was impossible to cause A-Fib in the obese or lean rats that had an open side port airway. But almost all the obese rats subjected to obstructive sleep apnea exhibited A-Fib. A small number of the lean rats subjected to obstructive sleep apnea also developed A-Fib.

From this experiment one can conclude that obstructive sleep apnea substantially increases A-Fib Induceability, and significantly more so in obese rats. If we can apply the results of this experiment to humans, we can conclude that obstructive sleep apnea combined with obesity makes someone significantly more at risk of developing A-Fib. On the other hand, just being obese may be a less significant factor in developing A-Fib.

Dr. Nattel went further and tried to identify the actual A-Fib mechanisms behind obstructive sleep apnea and obesity. Some of the rats were subjected to pharmacological autonomic blockade while others received muscle relaxants. Some of the rats who received the pharmacological blockade could no longer be induced into A-Fib, but a majority could. One can conclude that, “autonomic nervous system changes contribute to A-Fib promotion, but only account for a part of it.”

But the rats who received the muscle relaxant did not develop A-Fib. This may be because they didn’t experience the negative pressure generated in obstructive sleep apnea when the airway is closed off.

But why was A-Fib more induceable in the obese rats? The left atrial dimensions of the obese and lean rats control group were not significantly different, but with progressive apnea there was an almost two-fold increase in atrial dimensions which increased more in the obese rats than in the lean ones. Dr. Nattel tried to prevent this left atrial dilation by inserting a balloon catheter into the inferior vena cava thereby reducing venous blood return. This prevented A-Fib in 80% of the previously inducible rats. He concluded that there is, “strong, suggestive evidence that it is in fact left atrial distension that is responsible for the A-Fib susceptibility of the obese rats during obstructive apnea.” “A-Fib promotion is primarily due to acute left atrial enlargement, caused by forced inhalation against a closed airway, combined with left ventricular diastolic dysfunction and obesity.”

Dr. Nattel’s innovative experiment showed how sleep apnea is highly likely to cause A-Fib primarily by enlarging and remodeling the left atrium particularly in the obese but also in lean subjects as well.

If you or someone you know snores and/or stops breathing while sleeping and particularly if they are obese, it’s almost guaranteed they are remodeling and harming their heart and will eventually develop A-Fib. They need to have a sleep apnea study done ASAP and correct their breathing problem.

The overall mood of the 17^th Boston Atrial fibrillation Symposium seemed to be one of confident anticipation. Many presenters expanded on how, by next year, there will likely be four new anticoagulants approved by the FDA (dabigatran [Pradaxa] already FDA approved, rivaroxaban, apixaban, and edoxaban). Doctors and patients will finally have alternatives to warfarin.

    The dominant theme of this year’s Symposium was improved stroke prevention. On Friday, January 13, there were no less than nine presentations on stroke prevention, and the Thursday panel discussion of “Difficult Cases” mostly focused on anticoagulation problems.
    The second most discussed topic was Pulmonary Vein Reconnection after ablation---(the most urgent topic of greatest concern for A-Fib doctors and researchers).
    This year's Symposium featured a number of mini-symposia and individual presentations focusing on topics such as:

The Symposium also featured a great degree of presenter/audience interaction and participation. Each attendee had a remote clicker with 1 through 5 choices. A presenter would, for example, pose a case and give five different treatment options, then allow time for everyone to vote. The percentage of attendees voting for each choice would be almost immediately shown on screen. The presenters and audience would then discuss the results.

CATHETER-BASED OCCLUSION
In a presentation on the Surgical Management of the Left Atrial Appendage, Dr. Ralph Damiano, Jr. of Barnes Jewish Hospital in St. Louis, MO discussed, among other subjects, a disturbing case where a catheter-based occlusion device was inserted onto the Left Atrial Appendage (LAA) from inside the heart, but the insertion was unsuccessful. Part of the occlusion device was left protruding from the LAA into the Left Atrium with bare metal wires exposed.
In another disturbing incident at the Symposium, the live satellite presentation from Milan, Italy showed a different LAA occlusion device being inserted into a patient’s LAA. Though we saw in the pre-op how the catheter was flushed out with saline to prevent air bubbles from leaking into the Left Atrium, that's exactly what happened during the live case.

EDITOR’S COMMENTS:
    Even though inserting the Watchman device, for example, is a relatively simple procedure with a high success rate and relatively few complications, if a problem or mistake does happen, it can have a catastrophic result for a patient. For example, a device improperly inserted will most likely have to be removed by major heart surgery. An air bubble inside the heart can potentially cause an embolism, clot and stroke.
    This Editor in the past thought that the Watchman occlusion device was a wonderful development for an A-Fib patient who couldn’t or didn’t want to be on warfarin. But installing a foreign object inside the heart seems inherently dangerous. Unlike a catheter ablation which has a low risk of adverse events that usually can be corrected without any lasting damage, a mistake or problem inserting an occlusion device inside the heart can cause disastrous problems for patients.
    And there are now other options for patients such as a wider choice of anticoagulants or devices that close off the LAA from outside the heart such as the surgical AtriClip or the Lariat II. Patients should not have an occlusion device installed unless the doctor can guarantee a 100 percent success rate without complications. Anything less may result in catastrophic complications for patients.
    This editor predicts that, with the many different options now available to A-Fib patients, the FDA will not approve occlusion devices inserted from within the heart. Even though the failure risk is small, a failure can result in complications devastating for patients.

NOVEMBER 28, 2011
Dabigatran (Pradaxa)---Should We Worry?
    The Japanese Ministry of Health, Labor, and Welfare recently issued a safety advisory warning of the potential for adverse effects following the deaths of five patients. Of the deceased patients, one had kidney failure and four were over 80 years old. In Japan there were 81 reported cases of serious side effects, including gastrointestinal bleeding, out of 64,000 people who have used dabigatran since it was first introduced in Japan in 2011.
EDITOR'S COMMENTS
    81 out of 64,000 is a very low number of serious side effects, particularly compared to warfarin. In a recent study warfarin was implicated in 33% of "adverse drug events (ADEs)" for seniors requiring emergency hospitalizations.
    Of the five patients who died, dabigatran is counterindicated (shouldn't be used) in patients with renal failure. Caution is obviously needed in patients over 80 years old. They should be monitored more closely to determine if they have risk factors for bleeding. This should be reflected in the labeling of dabigatran.

    The Australian regulatory authority, the Therapeutic Goods Administration, issued a "safety advisory" on dabigatran because of an increase in the number of bleeding-related adverse events reports. The most common site of serious bleeding for dabigatran was the gastrointestinal track, whereas for warfarin it is intracranial.
EDITOR'S COMMENTS
    The clinical trials of dabigatran revealed that nearly two out of five patients could not tolerate dabigatran. The Pradaxa Fact Sheet from Boehringer Ingelheim states under "Adverse Reaction from RE-LY" (the clinical trial of Pradaxa): Patients on Pradaxa 150mg had an increased incidence of gastrointestinal adverse reactions (35%/yr) compared to warfarin (24%/yr).
    Dabigatran may not be the perfect substitute for warfarin. If you're taking dabigatran (Pradaxa), watch out for indigestion, burning, stomach pain (and weight loss). But which would you rather have---a hemorrhagic (intracranial bleeding) stroke or indigestion? On the other hand, based on the clinical trial date there is a danger that dabigatran over time may cause long-term damage to the gastrointestinal system. This is a decision you and your doctor have to make depending on how you react to dabigatran.
    Overall, dabigatran, though not perfect and not tolerated by all A-Fib patients, is nevertheless a welcome addition to the tools doctors have to prevent A-Fib stroke.

CAVEAT
    If you're taking dabigatran and have a major traumatic accident, emergency doctors have no antidote to stop you from bleeding to death (with the exception of emergency dialysis which is not easily done on patients with serious trauma and bleeding). Whereas doctors can rapidly reverse the anticoagulant effect of warfarin using vitamin K, plasma factor Vlla, and factor concentrates.
    Also, the degree of warfarin anticoagulation can be easily assessed, whereas no such tests exist for dabigatran.
    But the advantages of dabigatran may outweigh the chances of a traumatic accident like a car crash which may not be survivable any way. How likely are you to be in a traumatic accident? This is again a decision you need to consider with your doctor.

Wood, Shelley "Trauma patients on dabigatran prompt call for "pragmatic" trials, trauma surveillance." HeartWire, TheHeart.org. November 24, 2011
http://www.theheart.org/article/1317869.do

NOVEMBER 26, 2011
Dronedarone (Multaq)---Time to Stop Taking It?
     This report is a compilation of several recent news reports about dronedarone (Multaq) and what they mean for A-Fib patients.
     1. "Multaq should not be prescribed for patients with permanent A-Fib." according to Sanofi-Aventis' warning to doctors. In the PALLAS study, terminated early, patients on dronedarone were dying at more than twice the rate of those on a placebo. The ratio of stroke and hospitalization for heart failure was also more than twice as high.
     2. French health authorities concluded that the efficacy of dronedarone was "insufficient." This could lead to the drug being dropped from France's drug reimbursement program.
     The European Medicines Agency stated that, because of the increased risk of liver. lung and cardiovascular adverse events, dronedarone "should only be prescribed after alternative treatment options have been considered."
     3. Dr. Steven Nissen of the Cleveland Clinic told the Wall Street Journal that he thinks the drug is dangerous.
     4. Dr. Sanjay Kaul of Cedars-Sinai Medical Center in Los Angeles added, "It doesn't even appear safe in intermediate-risk patients.
     5. Dr. John Mandrola of Louisville stated, "I don't know any of my colleagues who would start a patient out on Multaq. It just doesn't work."
     6. The FDA publishes a list of drugs to monitor after having identified potential signs of serious risks or new safety information. Dronedarone appeared on this list for the fifth straight time.

     But according to Dr. Stuart Connolly (McMasters Un., Hamilton Ontario), one of the co-primary investigators of the PALLAS trial, patients with non-permanent A-Fib benefit from dronedarone, and he doesn't think this type of patient should be worried. (But is there that much of a difference between permanent and non-permanent A-Fib patients that we shouldn't be worried or concerned? For example, by the time liver damage shows up in tests, liver cells have already been damaged, probably permanently.)

EDITOR'S COMMENTS:
     So many red flags have been raised about dronedarone (Multaq) that anyone taking dronedarone should discuss with your doctor if you can take another antiarrhythmic med instead. If the worst fears about dronedarone are true, it may be both ineffective and dangerous. Why take a drug associated with increased strokes, hospitalizations, heart failure, liver damage, lung damage and death if it doesn't work? Even if it did work, the side effects probably wouldn't justify taking it.
     No antiarrhythmic drug is 100% safe and effective for all A-Fib patients. But until we get more favorable research on dronedarone, all A-Fib patients should probably consider not taking it, not just those in permanent A-Fib. It's not worth the risk of taking a drug that isn't very effective any way.

For a spirited, lengthy discussion of dronedarone, read Mellanie True-Hills' article/editorial http://www.stopafib.org/newsitem.cfm/NEWSID/353/What we have learned about Multaq/dronedarone
But in her own words, "The maker of Multaq is one of many organizations that has contributed so that we can do research and writing to give you the best content."

NOVEMBER 25, 2011
Successful A-Fib Catheter Ablation Improves Health
     It feels so great to be A-Fib free and in normal sinus rhythm after a successful Pulmonary Vein Isolation (PVI) procedure that one feels more healthy. But is one's health actually improved after a successful PVI?
    In an observational long-term study of the impact of A-Fib ablation, over 4,000 patients from the Murray, Utah Intermountain Medical Center were followed for over three years. Compared to matched controls who had A-Fib but did not have an ablation, ablated patients had a significantly lower risk of death, stroke, heart failure, cardiovascular hospitalization and dementia. (People with A-Fib have an increased risk of developing dementia, because blood is not being pumped properly to the brain and other organs when in A-Fib.)

Catheter Ablation Superior to Drug Therapy
    The article cited previous studies which showed that antiarrhythmic drugs, which attempt to return the heart to normal sinus rhythm, don't improve morbidity and mortality compared to leaving patients in A-Fib with rate control drugs, perhaps because current antiarrhythmic meds aren't highly effective, recurrence rates during therapy are high (44%-67% at 1 year), and adverse events and side effects are common.
    Catheter ablation was found superior to drug therapy in suppressing A-Fib and improving symptoms, exercise capacity, and quality of life.

Successful Ablation Patients More Healthy Than People Without A-Fib!
    The over 4,000 ablated patients were also matched with controls who did not have A-Fib. Ablated patients were more likely to have had hypertension, heart failure, and significant valvular disease---were more likely to be less healthy than the controls. But after three+ years of normal sinus rhythm, there was a trend towards lower long-term adverse events in the A-Fib ablation group compared to the "healthier" control group (with the exception of heart failure).

Editor's Comments:
We know that we feel better after a successful Pulmonary Vein Isolation (PVI) procedure. It makes intuitive sense that our heart and body would function better, that we would be more healthy after a successful PVI. But it's good to have studies that document this in no uncertain terms.
But what's even more interesting is that patients A-Fib free were to some extent healthier than matched controls who never had A-Fib, even though the patients with A-Fib probably had more health problems going in than the controls. The authors of this study didn't speculate on why this occurred. Could it be that those of us made A-Fib free value normal sinus rhythm more and take more steps to stay healthy and A-Fib free?

T. Jared Bunch, et al. "Patients Treated with Catheter Ablation for Atrial Fibrillation have Long-Term Rates of Death, Stroke, and Dementia Similar to Patients without Atrial Fibrillation." J Cardiovasc Electrophysiol. 2011 Aug;22(8):839-45. doi: 10.1111/j.1540-8167.2011.02035.x. Epub 2011 Mar 15.

SEPTEMBER 15, 2011
    Dr. Marcos Daccarett, MD, MSc, FACC, FAHA, FHRS has moved from the University of Utah Hospital to St. Luke's Idaho Cardiology Associates in Boise.

SEPTEMBER 12, 2011
Having Trouble Sleeping?---the Aspirin Your Taking May Be the Problem
    People with A-Fib are often prescribed the blood thinner aspirin to help prevent clots and A-Fib stroke. NSAIDs (aspirin, ibuprofen, etc.) work by inhibiting prostaglandin synthesis which is involved in pain and inflammation. But they are also involved in melatonin synthesis and body temperature regulation.
    A recent double blind study found that aspirin and ibuprofen suppressed melatonin synthesis and attenuated the normal circadian decrease in body temperature during nighttime hours. This alteration of normal sleep patters in healthy individuals by the NSAIDs aspirin and ibuprofen was not found, however, in all study subjects.
    (Editor's Comments: if you're taking aspirin, even at the lowest dosage 81 mg, and are having trouble getting to sleep, try taking the aspirin in the morning rather than in the evening before bedtime. However, you may find that even taking aspirin in the morning may still affect your sleep.
    NSAIDs are the most frequently prescribed medications worldwide. But one wonders why when considering the documented side effects to the gastrointestinal tract, liver, kidneys, central nervous system, endocrine system, and articular cartilage this article briefly documents.
    For example, "researchers estimate that 8-10% of the overall incidence of end-stage renal (kidney) disease is attributable to acetaminophen [Tylenol]. The risk is dose dependent with measurable increases of risk beginning at 105-365 pills per year or greater than 1000 pills per lifetime." What this means in non-medical language is if you take more than 1000 acetaminophen during your lifetime, you stand a good chance of permanently destroying your kidneys. For a 50-year-old that's only 20 pills a year. One wonders why so many doctors and hospitals in the US prescribe or recommend acetaminophen for pain relief, even for children. [Some researchers do not consider acetaminophen a NSAID, though it works by the same mechanism---inhibition of prostaglandin synthesis.] )
    Thanks to one of our readers for calling our attention to this article and to its importance. He had trouble sleeping when taking 81 mg of aspirin (baby aspirin). ayatingl(at)gmail.com

NSAIDs -- The Unintended Consequences Dynamic Chiropractic
October 20, 1997, Volume 15, Issue 22 by Alan Cook, DC

SEPTEMBER 12, 2011
NSAIDs Associated with A-Fib
    NSAIDs (nonsteroidal anti-inflammatory drugs such as aspirin, ibuprofen [Advil, Motrin], naproxen [Aleve, Naprosyn) and COX-2 inhibitors are associated with an increased risk of developing A-Fib and/or Flutter.
    A Danish study of 32,602 patients with A-Fib or Flutter found that the use of NSAIDs was associated with an adjusted 17% increased risk of developing A-Fib or Flutter. There was a slightly higher risk associated with the use of COX-2 inhibitors.
    New users had the highest risk. For those who filled a prescription for NSAIDs within the previous two months, they had a 46% chance of developing A-Fib/Flutter. For COX-2 inhibitors there was a 71% increased risk.
    A previous study based on the United Kingdom General Practice Research Database also found an association between the use of NSAIDs and A-Fib. But this study found the highest risk among long term users (for more than one year) rather than first-time users.
    But an "association" doesn't necessarily mean that NSAIDs cause or trigger A-Fib/Flutter. Perhaps an inflammation condition increases the risk of A-Fib on the one hand or prompts the use of NSAIDs on the other. According to Dr. Jerry H. Gurwitz (Un. of Massachusetts Medical School, Worchester), "The risk is unproven. But NSAIDs should be used with caution in high risk patients anyway."
    (Editor's Comments: though inflammation may produce fibrosis, lost of atrial muscle mass and thereby foster A-Fib, that doesn't explain how nearly one out of two new users filling prescriptions for NSAIDs developed A-Fib/Flutter within two months.
    Until further research clarifies these points, it's prudent to consider NSAIDs not just associated with A-Fib but actual triggers or causes of A-Fib.
    These Danish and British studies may be medical breakthrough research. Avoiding NSAIDs may help prevent the development and/or triggering of A-Fib/Flutter.)

NSAID use associated with risk of atrial fibrillation or flutter

NSAIDs and atrial fibrillation

BMJ

2011; 343:d2495 doi: 10.1136/bmj.d2495 (Published 4 July 2011)

SEPTEMBER 11, 2011
Elderly Shouldn't Use NSAIDs
    NSAID (nonsteroidal anti-inflammatory drugs---such as aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn) use among elderly patients with high blood pressure and coronary artery disease leads to increased mortality, heart attacks and stroke. Chronic NSAID users had a 60% increased risk of death, heart attack and stroke. And according to Dr. Anthony Bavry (Un. of Florida, Gainesville), "This association doesn't appear to be due to elevated blood pressure, because chronic NSAID users actually had slightly lower...blood pressure."
    Editor's Note: Many A-Fib patients are elderly. It's all too tempting to turn to NSAIDs to handle pains big and small. But what can we elderly do? Acetaminophen (Tylenol) is associated with kidney failure. COX-2 inhibitors have their own set of problems. Are there any pharmaceutical pain killers that are safe to take?
    We need to investigate "natural" pain killers. Are there natural pain relievers that would help us without causing bad side effects? Has anyone studied natural pain relievers which A-Fib patients might use? Here is a starting list of natural pain relievers:

NSAID use in elderly with hypertension linked to increased cardiac risk

Thanks to Ira David Levin for calling our attention to this article and for pointing out its importance for A-Fibbers.

SEPTEMBER 2, 2011
Silent Clots from Multielectrode Phased-RF Ablation Catheters
In two small studies of catheter ablation, Magnetic Resonant Imaging (MRI) revealed "subliminal (silent) intracranial embolic events" (clots, lesions) that normally would not have been detected if MRI weren't used. These non-randomized studies raise concerns that catheter ablation may cause small, unnoticeable clots or lesions in the brain. The studies compared Multielectrode Phased-RF Ablation Catheters (Medtronic Ablation Frontiers), conventional Irrigated-Tip Catheters (Navistar Thermocool, Biosense Webster), and CryoBalloon Catheters Arctic Front, Medtronic).
In one study using the Multielectrode Phased-RF Ablation Catheter 38.9% of patients (9 out of 27) experienced silent cerebral lesions. This was significantly more than a conventional Irrigated-Tip RF catheter (2 out of 27, 7.4%) or the CryoBalloon catheter (1 out of 23, 4.3%). (Some reports cite only the percentages which can be misleading, since the actual numbers of patients were so small.)

Why Lesions from Multielectrode Phased-RF Catheters?
Why would a Multielectrode Phased-RF Catheter produce so many small clots or lesions? Possibly because, unlike conventional Irrigated-Tip catheters, it is not irrigated. What may happen is, when heart tissue is heated, energy is transferred back to the electrode, which as it heats up can cause char. This char can break off and cause clots and strokes. Conventional Irrigated-Tip catheters are cooled by saline solution to reduce or eliminate this heat effect.

MRI-Detected Lesions may be Insignificant or may Reverse Themselves
A Medtronic spokesperson pointed out that the lesions detected by MRI have not been clearly linked to neurologic defect or cognitive decline, and that some studies have shown that the lesions detected have been shown to reverse on follow-up. (These MRI-detected lesions may not have any lasting effect or may resolve themselves much as a more serious TIA (Transient Ischemic Attack) often resolves itself and doesn't seem to have a lasting effect.)

But A-Fib Patients Should Still be Concerned
Any kind of lesions in the brain are cause for concern. In the words of Dr. Vivek Reddy (Mount Sinai School of Medicine, New York), "It can't be a good thing to have all this stuff in your brain." What do these silent ischemic lesions mean, how do they affect us? Dr. Jonathan Steinberg (Columbia College of Physicians & Surgeons, New York) sums up, "We don't know if some of this is reversible, or if it's such a small volume of damage that it ultimately is negligible or has no functional impact."

Need for Further Study
What needs to be done is to follow patients who have had these MRI-detected lesions to see if they are affected neurologically over time, to see if these lesions do indeed resolve themselves and disappear.

EDITOR'S COMMENTS:
     These studies, though small, seem to indicate that A-Fib patients should probably avoid ablations by Multielectrode Phased-RF catheters until these silent cerebral lesions are proven to be benign.
    But what about conventional Irrigated-Tip and CryoBalloon catheters? The number of silent lesions was so small in both studies that it's hard to make decisions based on such limited sample sizes. (One would expect the CryoBalloon catheter to produce less silent lesions. In the clinical trials, it was safer than conventional Irrigated-Tip catheters and produced less clots. See CryoBalloon Ablation Safer Than RF)
    However, there is a small but real risk of stroke during a RF catheter ablation procedure even with using an irrigated tip catheter (less than 0.5%³⁴). Stroke is less of a risk when using CryoBalloon ablation.

"Silent-embolization concerns mount for RF ablation catheter." http://www.theheart.org/article/1260023.do

Siklódy CH, Deneke T, Hocini M, et al. Incidence of asymptomatic intracranial embolic events after pulmonary vein isolation. J Am Coll Cardiol 2011; 58: 681-688. http://www.theheart.org/article/1237547.do

Gaita F, Leclercq JF, Schumacher B, et al. Incidence of silent cerebral thromboembolic lesions after atrial fibrillation ablation may change according to technology used: Comparison of irrigated radiofrequency, multipolar nonirrigated catheter and cryoballoon. J Cardiovasc Electrophysiol 2011; DOI:10.1111/j.1540-8167.2011.02050.x.

AUGUST 19, 2011
    New question answered in the FAQs (Questions) section:
"I'm scheduled to have Mini-Maze surgery. During the operation they close off the Left Atrial Appendage (LAA) to prevent clots and stroke. But a friend of mine had his LAA closed off, and now he can't exercise like he used to. Does closing off the LAA hurt the heart?"
Reasons to Close Off the left Atrial Appendage
    The rationale for closing off the LAA is that, in case the Mini-Maze fails which doesn't often happen, the patient is still protected from having an A-Fib stroke. 90%-95% of A-Fib strokes come from clots that originate in the LAA. In A-Fib, blood stagnates in the LAA and clots tend to form.
    Another important consideration is that closing off the LAA, even if a person is no longer in A-Fib, may still prevent a stroke. The LAA is where most clots originate. If a surgeon is already working on the heart, why not close off the LAA and reduce the patient's chance of having a future stroke? (If they didn't close off the LAA, they could be sued if a patient later had a stroke, even if the patient was no longer in A-Fib.) Life (no stroke) is more important for most people than a possible reduced exercise intolerance.
    In the future even people without A-Fib may have their Left Atrial Appendage closed off if it prevents or reduces the risk of a stroke. There are currently a variety of devices, surgical and non-surgical, which can do this.
Functions of the Left Atrial Appendage
    The LAA functions like a reservoir or decompression chamber or a surge tank on a hot water heater to prevent surges of blood in the left atrium when the mitral valve is closed.²⁸⁶ Without it there is increased pressure on the pulmonary veins and left atrium which might possibly lead to heart problems in the future.
    Closing off the LAA also may reduce the amount of blood pumped by the heart and may possibly result in exercise intolerance for people with an active life style. (In dogs the LAA provides 17.2% volume of blood pumped.²⁵⁷) Could studies be done to test heart function and pumping ability pre- and post- LAA closure?
    The LAA also has a high concentration of Atrial Natriuretic Factor (ANF) granules which help to reduce blood pressure.287
    But these functions for most people aren't nearly as important as reducing the threat of a stroke.

AUGUST 10, 2011
    Added to the THE MAZE AND MINI-MAZE SURGICAL OPERATIONS section.
Cutting Out or Stapling Shut the Left Atrial Appendage
    One considered advantage of the Mini Maze operations is that the Left Atrial Appendage (LAA) is cut out and/or stapled shut. Most A-Fib blood clots which cause stroke come from the Left Atrial Appendage. By cutting out or closing off the Left Atrial Appendage, most but not all risk of stroke is eliminated even if you are still in A-Fib.
    However, the success rate for closing off the LAA by surgery currently isn't anywhere near 100%. In a study by 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
Should the LAA be routinely cut out or stapled shut in all A-Fib patients?
    Some question the need or benefit of removing the Left Atrial Appendage (LAA) if someone is no longer in A-Fib.
    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.
    Cutting out or stapling shut the LAA 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. (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

AUGUST 9, 2011
    Added to the THE MAZE AND MINI-MAZE SURGICAL OPERATIONS section.
Mini-Maze Surgeries with Left Atrial Lesions
    Scarring in the heart 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. Circulation, nerve signal pathways, heart muscle fibers, transport function, etc. may be affected.
    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 extensive ablation lines on the left atrium. But we don't know if this extensive scarring is necessary or appropriate for all cases of A-Fib.
    Patients should ask their surgeons if significant 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?

JULY 19, 2011
Dronedarone (brand name Multaq) "Risk of Severe Liver Injury."
    The FDA notified healthcare professionals and patients about cases of rare, but severe liver injury, including two cases of acute liver failure leading to liver transplant in patients treated with the heart medication dronedarone (Multaq). Information about the potential risk of liver injury from dronedarone is being added to the WARNINGS AND PRECAUTIONS and ADVERSE REACTIONS sections of the dronedarone labels.
    If you start feeling nausea, vomiting, fever, anorexia, malaise, fatigue, right upper quadrant pain, jaundice, dark urine, or itching, it's recommended you stop taking Multaq and get in touch with your doctor ASAP.
    Your doctor should be testing you for "hepatic (liver) serum enzymes" especially during the first 6 months of treatment.
    (Editor's Note: It's disappointing that the FDA had to issue this risk notification about Multaq. We can't help but ask if Multaq may cause long-term damage to the liver, even though it's tolerated in the short term. How many people taking Multaq have had their liver serum enzymes tested, know what their benchmark liver serum enzymes numbers are, and keep track of any rise (not just whether they are in an acceptable range)?
    Is Multaq destined to be yet another antiarrhythmic med that causes more problems/side effects than it solves? )
http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm240110.htm

JUNE 25, 2011
Michelle Straube is walking the Alps to promote A-Fib Awareness! After being in A-Fib for 30 years she was made A-Fib free in 2009. Check out her blog Into the Heart of the Alps for Atrial Fibrillation Awareness: http://bit.ly/hHPG2f.
"We’re leaving for the first 22 days of our trek this Sunday — still so much to do, but so excited. Just walking uphill fast is a miracle, but now I can do that and talk at the same time, or carry a 20-lb backpack and make it up without wheezing or dizziness. Life is so good!" See Michelle Straube's story.

JUNE 24, 2011
New answer in the Questions/FAQs section of A-Fib.com:
64. "I've had a successful Pulmonary Vein Ablation (Isolation) procedure a year ago. I'm in normal sinus rhythm and have been A-Fib symptom free. Will my A-Fib eventually return over time, or am I permanently cured? Someone told me A-Fib is a progressive disease that is incurable and will eventually come back." (Thanks to Clark for asking parts of this question and to A-Fib Support Volunteer Jerry for helping write this answer.)

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

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

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

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

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

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

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

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

TOO MANY ABLATIONS/SURGERY
You should be concerned about having too many ablations/surgery. Excessive scarring of the left atrium can render it electrically inert or "dead." Transport function, the ability of the left atrium to pump, may be compromised or destroyed. It’s possible during a difficult ablation to simply ablate everywhere in the left atrium in hopes of hitting all the A-Fib generating spots. But this approach can permanently damage the ability of the left atrium to pump. The author is aware of cases where, after only two ablations, a patient’s left atrium was so scarred that it no longer functioned properly, though the patient was still in A-Fib. In one case the A-Fib trigger was found in the right atrium.

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

Current surgical approaches probably have less chance of being an effective option in your case. They can’t reach all the areas of the heart where A-Fib signals can originate. (Surgical approaches currently can only be done once.)

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

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

aPRIL 26, 2011
    New story in Personal Experiences: Overcoming Silent A-Fib---Ablation by Dr. Patrawala

APRIL 24, 2011
    Fibrosis Predicts Stroke Risk
   In a study from Dr. Nassir Marrouche at the Comprehensive Arrhythmia Research and management Center in Utah, Stage IV (over 35% fibrosis) patients were four times more likely to have a stroke than patients with a low level of atrial fibrosis. And the level of fibrosis didn't always correlate with standard CHADS₂ risk scores of stroke. 16.5% of patients with a CHADS₂ score of 0 (low risk) and 18.5% with a score of 1 (intermediate risk) had Stage IV atrial fibrosis.
    Whether you were in paroxysmal or persistent A-Fib didn't seem to have an impact on the likelihood of stroke rate.
    Women were three times more likely to have a stroke than men. The researchers hypothesized that, because men tend to get treatment for A-Fib sooner, women had more extensive remodeling and fibrosis than men, which led to a higher stroke risk.²⁶⁴
    (Editor's Observations: MRIs to measure fibrosis in the heart should become a routine diagnostic tool for anyone in A-Fib. According to this study, the CHADS₂ method of evaluating risk of stroke doesn't work in many cases. Should we retire the CHADS₂and replace it with a more empirical, scientific method such as fibrosis measurement?
    Some people have argued that there is less risk of stroke if one is in continuous A-Fib rather than paroxysmal (occasional), because one might be more at risk of a clot when the heart stops and starts beating normally. But this study indicates that whether one is paroxysmal or persistent doesn't seem to influence the risk of stroke.
    The finding that women are three times more likely to have a stroke than men should be a wake-up call for doctors (and of course for women)! If women hear from their doctor "it's all in your mind," or Take a valium," it's time to get a second opinion ASAP. An A-Fib stroke is a fate worse than death, if you live through it. Doctors should become more aware of the increased danger A-Fib presents to women.)

APRIL 22, 2011
    New observations added to the Maze/Mini-Maze Surgical Operations section under Treatments.

    Patients often ask if a Mini-Maze surgery is overkill for simple cases of Paroxysmal (occasional) A-Fib. Many 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."²⁵⁵Since 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
     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.
     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.

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 around $15,000 higher for surgery 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, though not approved by the FDA, have sales of about $100 million a year.²⁶⁰
     Doctors may use medical devices for "off-label" treatments. But companies are allowed to market them only 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. AtriCure, of West Chester, Ohio, 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). The company did not admit wrongdoing. Estech, of San Ramon, California, agreed to pay $1.5 million to settle such charges with the Justice Department, also without admitting wrongdoing.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

APRIL 22, 2011
    New observation (in red) about Dr. Edgerton's presentation on Hybrid Ablation at the 2011 Boston A-Fib Symposium.
    Dr. Edgerton prefers the approach where both the Surgeon and the EP take their best shot working together on a patient, the patient has a single anesthetic, and presumably a shorter hospital stay. (Dr. Edgerton's approach is sequential in that first the surgeon works on a patient, then the EP takes over. In a different "Hybrid" approach, as used for example by Dr. Wilber Su of Heart Rhythm Specialists of Arizona, both the surgeon and the EP work on a patient at the same time. The EP can, for example, tell the surgeon immediately if a particular lesion is effective.)

APRIL 14, 2011
    PVA(I) Improves Ejection Fraction
    A successful Pulmonary Vein Ablation (Isolation) (PVA(I) reverses many of the remodeling effects of A-Fib. For example, enlargement of the left atrium and the ability of the atria to contract can be reversed after a successful catheter ablation.⁵⁸ But there is some disagreement among researchers as to whether a successful PVA(I) over time improves Ejection Fraction.²⁵⁸
    In a study from the Bordeaux group, A-Fib patients with Congestive Heart Failure and an ejection fraction of less than 45% (normal ejection fraction range is 56%-78%), had a PVA(I). After approximately 12 months, 78% were A-Fib free without meds. They had significant improvement in left ventricular function including increases in ejection fraction of approximately 21% (as well as exercise capacity, symptoms, and quality of life). The ejection fraction also improved significantly (24%) in the control group of A-Fib patients without Congestive Heart Failure.²⁵⁹
    (Editor's Note: It's not all that surprising that A-Fib patients with a low ejection fraction would improve after a successful PVA(I). But the control group without Congestive Heart Failure also improved their ejection fractions. In this study a successful PVA(I) improves ejection fraction even if one has a relatively normal ejection fraction to begin with.)
²⁵⁹Hsu, Li-Fern et al. "Catheter Ablation for Atrial Fibrillation in Congestive Heart Failure."
N Eng J Med 2004; 351:2373-2383 December 2, 2004.
http://www.nejm.org/doi/full/10.1056/NEJMoa041018

APRIL 13. 2011
    New question answered in the FAQs section:
    "I had been in A-Fib for a number of years. I know A-Fib remodeled my heart. My left atrium is enlarged and I probably have developed a lot of fibrosis. But I've just had a successful A-Fib ablation and feel great. Will my left atrium, ejection fraction, fibrosis, etc. improve?" (Thanks to Mark for this question.)
    Pulmonary Vein Ablation (Isolation) [PVA(I)] is a relatively new procedure. We don't have a lot of data on its long term effects.
    Obviously your atria function much better after a successful PVA(I). Your atria pump more blood into your ventricles like a normal heart. Any electrical remodeling effects of A-Fib have probably been reversed. One long term study indicates that many of the bad remodeling effects of A-Fib such as enlargement of the left atrium and the ability of the atria to contract can be reversed after a successful catheter ablation.⁵⁸
    In an analysis of 17 different studies enrolling 869 patients, a successful catheter ablation significantly decreased (improved) left atrial diameter and volume, but had no significant difference in ejection fraction and actual emptying fraction.²⁵⁸ (If before an ablation one's ejection fraction is low, one would expect an improvement over time as the heart becomes stronger. But for someone with a normal ejection fraction before ablation, there may not be much of an improvement. "Ejection Fraction" just measures what the ventricle does with the blood it receives, not whether it receives more or less blood from the left atrium.)
    A Bordeaux group study using Pulmonary Vein Isolation and Linear Lesions with an average follow-up of eleven months showed that left atrial volumes fell, but also that left atrial contractual and filling function almost returned to normal for Paroxysmal patients. For Chronic patients, left atrial contraction was low after ablation, but after eleven months it improved considerably. The study also showed improvements in ventricular, diastolic and systolic function. This improvement occurred even if patients had reoccurrences of A-Fib. (Boston A-Fib Symposium 2006 Dr. Wilber).
    In another study from the Bordeaux group, A-Fib patients with Congestive Heart Failure and an ejection fraction of less than 45% (normal ejection fraction range is 56%-78%), had a PVA(I). After approximately 12 months, 78% were A-Fib free without meds. They had significant improvement in left ventricular function including increases in ejection fraction of approximately 21% (as well as exercise capacity, symptoms, and quality of life). The ejection fraction also improved significantly (24%) in the control group of A-Fib patients without Congestive Heart Failure.²⁵⁹
    (It's not all that surprising that A-Fib patients with a low ejection fraction would improve after a successful PVA(I). But the control group without Congestive Heart Failure also improved their ejection fractions. In this study a successful PVA(I) improves ejection fraction even if one has a relatively normal ejection fraction to begin with.)
    One A-Fib remodeling effect that will probably not improve is fibrosis. Fibrosis is most likely irreversible. See Structural Remodeling in A-Fib.

APRIL 10, 2011
    DABIGATRAN (PRADAXA) INDIGESTION, BURNING, STOMACH PAIN, (WEIGHT LOSS) SIDE EFFECTS
    If you've started taking Pradaxa, watch out for indigestion, burning, stomach pain (and weight loss). These are listed as common side effects of Pradaxa. As many as 35% of people taking Pradaxa may experiences these symptoms. There is a fine line between allowing one's body to get used to a new drug, and deciding this drug isn't for me because of its bad side effects.
    The Pradaxa Fact Sheet from Boehringer Ingelheim states under "Adverse Reaction from RE-LY" (the clinical trial of Pradaxa):
    • Patients on Pradaxa 150mg had an increased incidence of gastrointestinal adverse reactions (35%/yr) compared to warfarin (24%/yr).
     • The discontinuation rate due to drug-related adverse events was 21% for Pradaxa 150mg and 16% for warfarin.
    "In addition to bleeding, Pradaxa can cause stomach upset or burning, and stomach pain." (Pradaxa Fact Sheet 101910.pdf)

    (Editor's Note: In the RE-LY clinical trial nearly 2 out of 5 people had gastrointestinal adverse reactions. 35% is a very high rate of adverse reactions. Pradaxa may not be the wonder drug we've all been hoping would replace warfarin. If it has such bad side effects, it may be damaging many more people's stomachs over a longer period of time.)
http://www.drugwatch.com/pradaxa/side-effects.php

APRIL 9, 2011
LARIAT ii SUTURE DELIVERY DEVICE
    Most A-Fib strokes (90-95%) come from clots which form in the Left Atrial Appendage. One strategy to prevent A-Fib stroke is to close off the Left Atrial Appendage. In most cases this is as effective as taking blood thinner medications. Though, as with blood thinners, it isn't an absolute guarantee you will never have an A-Fib stroke.
    A novel noose device to close off the Left Atrial Appendage is inserted from outside the heart (Lariat II, SentreHeart, Inc., Palo Alto, CA) (unlike for example the Watchman device which is inserted into the LAA from inside the heart). It is used in cases where the patient can not tolerate anticoagulants like Coumadin. (The Watchman device requires a patient be on anticoagulants for a couple of months.)
    From the inside of the heart a balloon is placed inside the Left Atrial Appendage to expand it and make it accessible to the noose device which is inserted from the outside of the heart. The positioning balloon is withdrawn before the Lariat noose is closed around the base of the Left Atrial Appendage. The noose completely closes off the Left Atrial Appendage which dies and is no longer electrically active. The Lariat II snare device has been approved by the FDA.
    The Lariat device was invented by Dr. William E. "Billy" Cohn, Director of Minimally Invasive Surgical Technology at the Texas Heart Institute at St. Luke's Episcopal Hospital. (Thanks to Beverly Stansfield for calling our attention to the importance of this device.)

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

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

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

APRIL 1, 2011
HALF OF ALL A-FIB DUE TO AVOIDABLE RISK FACTORS
    There are factors somewhat under our control which my influence or trigger A-Fib, such as hypertension, diabetes, obesity and smoking. One study says that half of all cases of A-Fib are due to the above cardiovascular risk factors, with hypertension the strongest predictor of A-Fib.²⁵³(Editor's Comment: One wonders why the study didn't also mention binge drinking as a cause or trigger of A-Fib. That's certainly something we have control over.)
    Maintaining a healthy diet and life style may help prevent A-Fib. But don't count on them to make you A-Fib free once you develop A-Fib. However, anything that makes you more healthy overall might influence the amount and severity of A-Fib attacks.
    The study also found that African Americans have a lower risk of developing A-Fib, even though they have more risk factors for A-Fib, such as high blood pressure and obesity.²⁵³

MARCH 30, 2011
most beta-blockers can have a harmful effect, except carvedilol (Coreg)
    A new study casts doubt on the effectiveness of most beta-blockers which "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.

MARCH 23, 2011
Report on the Boston A-Fib Symposium 2011 continued, part #10":

Improving Results with the CryoBalloon Catheter

Dr. Wynn Davies of St. Mary’s Hospital in London, England discussed the four types of catheters producing encircling lesions---balloon catheters (Cryo and Laser) and curvi linear multi-electrode and mesh catheters which use multi-phase RF. See Balloon Catheters and MultiElectrode RF Ablation Catheters.

He has been using the Cryo Balloon catheter and had many tips on its use. He prefers to use an extra stiff guide wire for extra support and because it is more capable of bending into difficult branches of the PVs. Once the balloon is opened, it can be pushed into the PV antrum as hard as one likes. The contrast dye is used to show there is no leakage. When the Cryo power is applied, it produces an excellent freeze and isolation.

A catheter is placed in the Superior Vena Cava to pace the phrenic nerve whenever Cryo energy is applied to the right PVs. The phrenic Nerve runs very close to the Right Superior Vein and can sometimes run close to the Right Inferior Vein. He waits for cryo adherence before starting phrenic nerve pacing.

He primarily uses the larger 28mm balloon catheter. He starts in the left upper vein, then moves to the left lower vein, then moves to the right upper and lower veins. The encircling lesions overlap each other.

He applies Cryo energy for five minutes per ablation, but others have used 4-6 minutes. Further studies are ongoing to determine how much time is necessary for a good CryoBalloon ablation.

In a European study of 350 patients, an average of 11 Cryo ablations were required to isolate the PVs (under 3 per vein). 97% of the veins were isolated, the vast majority with the larger 28 mm balloon. 75% of Paroxysmal patients were A-Fib free after 18 months. Fluoroscopy time was around 40 minutes. Ablations times averaged 100 minutes less than RF. There were 26 Phrenic Nerve Palsy cases, 24 of those cases used the smaller 24 mm balloon catheter (the smaller balloon may penetrate too deeply into the vein and get too close to the Phrenic Nerve).

Coping with Reconnection
    Dr. Hans Kottkamp of the Hirslanden Heat Center in Zurich, Switzerland, discussed how to recognize and deal with PV reconnection.
    He showed how measuring Entrance Block alone may not reveal gaps in ablation lines. Both Entrance and Exit block (bidirectional block) are necessary to reveal gaps.
    He discussed studies in which doctors waited either 30 minutes or 60 minutes after an ablation to check for reconnection. 1/3 of early reconduction can be found if one waits 60 minutes to map for bidirectional block and close any gaps. Clinical outcomes are better if one waits 60 minutes rather than only 30.
    But he pointed out that bidirectional conduction block is just a functional end point. It can not differentiate between reversible and irreversible tissue excitability after ablation.
    He suggested that adenosine might be used to identify reversible tissue damage after ablation. "Adenosine restores PV LA conduction by hyperpolarizing PV cells and thereby enhancing sodium current availability." It may reveal potentially reversible tissue injury which will react differently than tissue with permanent injury.
    He pointed out that RF tissue change including edema (swelling), and perhaps inflammation may contribute to late reversibility and reconnection.

MARCH 7, 2011
Report on the Boston A-Fib Symposium 2011 continued, part #9:

MINISYMPOSIUM ON TECHNIQUES IN A-FIB ABLATION

Where and What to Ablate in the Right Atrium
    Dr. Young-Hoon Kim from the Korea University Medical Center, Seoul, Korea, showed how in cases of long standing persistent (Chronic) A-Fib it is often necessary to ablate not only in the left atrium, but in the right atrium as well. CFAEs are often found particularly in the Crista Terminalis and High Septum areas. They are less frequently found at the Low Septum, the junction of the Superior Vena Cava and the Right Atrium, the Sinus Venosum, and the Neck of the Right Atrial Appendage. But when ablating in the Right Atrium, special attention must be paid to not damage the Sinus Node, AV Node, and Phrenic Nerve Sites.

    The Role of Left Atrial Appendage Isolation in A-Fib Ablation
    Dr. Andrea Natale of the Texas Cardiac Arrhythmia Institute in Austin, TX, described how in cases of patients needing re-do ablations or patients with long standing persistent A-Fib with extensive scarring/fibrosis (over 50%), triggers often originate from the Left Atrial Appendage (LAA). By electrically isolating the LAA through segmental ablation or more extensive ablation, 71% of these difficult patients were rendered A-Fib free. (They also found many A-Fib triggers in the Coronary Sinus.) Dr. Natale stressed the need to map and record from the LAA first, that A-Fib signals from the LAA can spread quickly throughout the heart and be mistakenly identified as coming from other areas.
    Does electrically isolating the LAA harm how the LAA functions (LAA velocity and mitral inflow)?Dr. Natale found that 2/3 of patients' LAAs functioned completely normally even though they were electrically disconnected. He doesn't know why.
    (The author has written Dr. Natale to ask how the other 1/3 of patients with an electrically isolated LAA were affected.
    Does electrically isolating the LAA make patients more susceptible to clots forming in the LAA?
    Dr. Natale's findings compliment and confirm other research which points out the importance of the LAA in difficult A-Fib cases, such as the work of the French Bordeaux group which ablates the base of the LAA as part of the first step in ablating for Chronic A-Fib. See Bordeaux Treatment for Chronic A-Fib.)

MARCH 5, 2011
    New question answered in the FAQs section:
"I know I'm overweight. Doctors list me as "morbidly obese." But my heart starts racing whenever i try to exercise, because of my A-Fib. What can i do? Should I get a Pulmonary Vein Ablation (PVA)?"
    EPs (Electrophysiologists) may be reluctant to do a PVA in your case. Today's imaging systems have difficulty seeing through significant fat mass to get a clear picture of the heart.
    An EP may refer you to a surgeon for a Mini-Maze operation which is done under general anesthesia and is considered more traumatic, invasive, and risky than a PVA and, like a PVA, isn't a guaranteed success. (See Pros and Cons of a Mini-Maze Operation.) But it may be your best option. (Make sure you discuss with the surgeon the risks of general anesthesia for someone overweight. Your heart may have a hard time beating properly under general anesthesia with the extra weight around it.)
    The author also struggles with a weight problem, as most of us do, and doesn't have any good advice for losing weight. But if you could find a way to lose some of your weight, then you'd have the option of getting a PVA to fix your A-Fib.

FEBRUARY 23, 2011
    Report on the Boston A-Fib Symposium 2011 continued, part #8:
MINISYMPOSIUM ON TECHNIQUES IN A-FIB ABLATION

    Measuring Quality in the EP Lab---Public Reporting
    Dr. Douglas Packer of the Mayo Clinic in Rochester, MN discussed a topic very important to both doctors and patients---how to measure and report on quality in the EP Center.
    "Measure something, then you will know something."
    "You can't manage what you can't measure."
    The new health care law will require in two years that A-Fib centers publicly report measurements of efficacy, safety, and process (not just outcome). The Heart Rhythm Society has a task force to develop Performance Measures for A-Fib. Forms are available for doctors to use. The task force is trying to develop:
    • Clear and Explicit Definitions
    • Clinical Coherence of the Variables (a common language and terms)
    • Sufficient and High Quality Timely Data
    • Designation of Appropriate Reference Times
    • Use of Appropriate Outcome and Standard Periods of Assessment and Observation
    Dr. Packer described the Mayo Clinic's recent experience with collecting data for the SAFARI Registry. One nurse had to be taken off line for two weeks to do the work. That kind of commitment isn't sustainable for the average EP lab. The work needs to be distilled down to something doable.
    But Dr. Packer pointed out that if EP labs don't do the work, third parties will, including self-appointed watchdogs that have nothing to do with the process.

    Jet Ventilation
    Dr. Francis Marchlinski of the Un. of Pennsylvania discussed how to improve catheter stability during ablations by:
    1. Using detailed landmark imaging to identify anatomic features like rid FlexCath® Steerable Sheath

ges which might cause stability problems,
    2. Using a steerable sheath catheter (FlexCath) which can bend 90 degrees and is more flexible than a non-steerable sheath catheter,
    3. Using High Frequency Low Volume Jet Ventilation to limit respiration movement. A low volume high pressure "jet" of oxygen flows into the airway for a brief time but at a high frequency. The patient receives enough oxygen, but with very little respiration movement. Because the catheter is stable and not affected by respiration movement, more effective lesions can be made.
    Dr. Marchlinski's colleagues were so impressed and enthusiastic about using Jet Ventilation that he couldn't pry it away from them to do a randomized study. He did observational studies which showed that when using Jet Ventilation (and steerable catheters), outcomes improved. Less veins reconnected after waiting 30 to 60 minutes after an ablation, and also after 6 months. PVI times were shorter. Patients who had to come back for a repeat ablation had less veins reconnected and smaller segments of veins that needed to be ablated.
    (Editor's Comments: Using Jet Ventilation is a potential game changer for EPs (and perhaps for Surgeons also). Jet Ventilation is a medical breakthrough that could significantly improve catheter ablation.)

"I'm getting by with my Atrial Fibrillation. With the recent improvements in Pulmonary Vein ablation techniques, should I wait till a better technique is developed? What improvements are being developed? Are any worth postponing an A-Fib ablation I have scheduled?" (Thanks to Tom Price for this question.)

    In general I wouldn't wait on having a PVA. A-Fib is a progressive disease that tends to get worse over time. In a process called "remodeling" your heart may change physically and electrically if you have A-Fib long enough. It's important to be cured as soon as possible. See Overview. For example, in a year you have approximately a 50% chance of moving from Paroxysmal (occasional) to Persistent/Chronic which is harder to cure.¹⁶⁴
    Current RF Ablation techniques are very effective. Many doctors have years of experience doing them. In this author's opinion, current innovations being developed aren't going to be major game changers. But this is a decision your and your doctor need to make.
    With today's current Pulmonary Vein Ablation (Isolation) procedures using Radio Frequency Catheters, you have an 70-85% chance of being cured permanently (in cases of Paroxysmal A-Fib).^17,41 (The other 15%-25% often are significantly improved, if not permanently cured.) Your odds aren't going to get much better than that.

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

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

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

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

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

Rotational Angiography is currently not in wide use.

BALLOON CATHETERS
    CRYOBALLOON CATHETER

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

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

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

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

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

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

REMOTE CONTROL ABLATION---HANSON, STEREOTAXIS
    REMOTE ROBOTIC NAVIGATION

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

   REMOTE MAGNETIC NAVIGATION

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

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



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

THE WATCHMAN DEVICE
    In this author's opinion, the most important recent innovation for patients is the Watchman Device. The theory behind the Watchman Device is most A-Fib clots originate in the Left Atrial Appendage (LAA). The Watchman Device closes off the LAA where 90-95% of A-fib strokes come from. It's a very low risk procedure that takes only a short time to install. Then you would usually not need to be on blood thinners.
    Here's how it works:
Once a patient's Left Atrial Appendage is measured, a wide-sheathed catheter with a spline is used to insert the Watchman device

which has a self-expanding Nitinol (a special metal) open-ended circular frame. The atrial surface of this frame is covered with a thin, permeable 160 μm (micron) pore filter made of polyester material (Polyethylene Terephthalate known as Dacron or PET). This filter allows blood to pass through while stopping clots. Little hooks or anchors called fixation barbs at the middle of the device make sure it is attached firmly to the LAA wall. The Watchman device comes in multiple sizes from 21mm to 33mm to accommodate the different sizes of LAAs.
Before the catheter is removed (which fixes the Watchman device in place), contrast agents are used to make sure the Watchman device is stable and entirely closes off the LAA opening. Over time heart tissue

grows over the polyester (PET) material so that it completely closes off the LAA with smooth heart tissue similar to other heart surfaces. In this Occlusion slide, heart tissue has completely covered the Watchman device after only nine months.
Some doctors are inserting the Watchman device in as little as 20 minutes. It is a low risk procedure with no surgery or ablation involved.
Patients on Coumadin continue to take it for six weeks after the Watchman device is inserted. They are then examined using a TEE (Transesophageal Echocardiogram) to make sure there is complete closure of the LAA. At that time they are taken off of Coumadin.

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

fEBRUARY 18, 2011
    Explanation of credentials listed after doctors' names and what they mean:
    Over the last five years there has been an astounding and welcome growth in the US of centers and doctors who do Pulmonary Vein Ablation (PVA) procedures. But some are low volume centers with limited facilities who may do as little as 20 PVAs a year. It's hard to quantify experience with specific numbers. But if a doctor only does 20 PVAs a year, that may not be enough to maintain and develop ablation skills. [Currently there is no data base available which lists how many PVAs a doctor does a year or how experienced he/she is.]
    Every A-Fib patient must do their own home work. You need to ask a prospective doctor and/or medical center how experienced they are, how many PVAs do they do a year, what is their success rate, what complications have they had. Most doctors and centers will welcome these questions and respond frankly to you. If they don't, that may be a sign you need to look elsewhere. See Questions For Doctors.
    The author admits to making a mistake in not listing credentials after a doctor's name and is in the process of correcting this. A-Fib Ablation is the most difficult ablation EPs perform, but currently any EP is allowed to do them, even if they haven't passed their EP board exam. The credentials after a doctor's name may help patients distinguish more experienced leaders in the field.
    Here are some of the credentials you may see after a doctor's name and what they mean. [You can check on a doctor's Certification yourself at http://www.abim.org/services/verify-a-physician.aspx]:
    • FACC Fellow of the American College of Cardiology. Designates a Cardiologist who has completed a minimum of ten years of clinical and educational preparation and passed a rigorous two-day exam given by the American Board of Internal Medicine. It's not an absolute requirement for an EP, but most EPs have passed this Cardiology Board exam.
    • FHRS Fellow of the Heart Rhythm Society. Not an academic title and not limited to physicians. Membership is based on peer review. Designates heart rhythm professionals working in the field of electrophysiology and/or pacing, provided that the majority of their time is not devoted to marketing and/or sales. Most EPs in the US with FHRS credentials have also achieved FACC. Internationally this may not be the case.
    • CCDS Certified Cardiac Device Specialist. Designates an EP who has passed an exam for cardiac devices such as pacemakers. The exam is given by the International Board of Heart Rhythm Examiners (IBHRE) affiliated with the Heart Rhythm Society. This credential may not be totally relevant to A-Fib ablation.
    • MBBS Bachelor of Medicine, Bachelor of Science. Awarded on graduation from medical school in various countries which follow the tradition of the United Kingdom. (Like an MD.)
   Currently there is no exam or peer review or certification identifying EPs who are experienced and competent in performing Pulmonary Vein Ablations. Patients need to do their own home work to identify EPs who can help them. See Questions For Doctors.

    The Doctors listed on A-Fib.com can also be found on the Heart Rhythm Society Web site.

FEBRUARY 16, 2011
Report on Boston A-Fib Symposium 2011 continued, part 7:

A-FIB AND DEMENTIA
    Dr. T. Jared Bunch of the Intermountain Medical Center in Utah, in the question and answer session after his talk, gave an example that summed up his presentation. He described how in the hospital he was talking with his patient, a University Professor. The patient would begin a sentence, go into A-Fib and not be able to finish the sentence. Then he'd go back into sinus and finish the sentence. A-Fib was causing him to loose cardiac output and volume of blood to the brain.

Common Causes or Mechanisms of Both A-Fib and Dementia
    Dr. Bunch pointed out that A-Fib and Dementia are two diseases that seem to parallel each other. Like A-Fib, Dementia seems to increase with age, diabetes, hypertension, heart failure,
smoking history, and systemic inflammation. His center has identified other mechanisms of both A-Fib and Dementia:
    • Vitamin D Deficiency
    • ApoE/Genetics   (Dr. Bunch didn't have time to elaborate on this genetic component of both A-Fib and Dementia. The author is corresponding with him to obtain more information on this potentially very important genetic finding.)
    The above factors cause Microperfusion Deficit (less blood to the brain) and Chronic Hypoxia (loss of oxygen). They often develop Thromboemboli (mini clots) and vascular problems.

Ablation Decreases Risk of Dementia and Risk of Stroke and Early Death
    Dr. Bunch cited several studies and the work of Intermountain Healthcare which showed that people with A-Fib who had an ablation had about the same risk of Dementia as normal people, while people with A-Fib who didn't have an ablation had much more risk of developing Dementia. But he acknowledged that these studies may be selecting a healthier population rather than ablation having an effect on its own. (In this patient's opinion, ablation is probably responsible for decreasing the risk of Dementia by improving blood flow to the brain.)
    And people with A-Fib who had an ablation had about the same risk of having a stroke and risk of dying within three years as normal people, while people with A-Fib who didn't have an ablation were likely to get a stroke within 4-5 years and were more likely to die within three years. In particular, A-Fib patients who developed Alzheimer's died within six months.

Supplements and Drugs to Prevent Dementia
    Supplements
    Dr. Bunch discussed various supplements used to prevent Dementia:
    • Antioxidant vitamins (E, C, Beta carotene, Flavonoids)
        They may decrease brain lesions associated with free radical exposure, but evidence is mixed.
    • Vitamins B6, B12, Folate, D
        Low levels of folate and D are associated with increased risk of Dementia. Dr. Bunch found that Vitamin D deficiency tracks with the development of both Dementia and A-Fib, but said it is unknown if supplementation reduces risk. (Intuitively one would expect that increasing Vitamin D levels would have a preventive effect on Dementia and possibly on A-Fib.)
    • Omega Fatty Acids/Fish Oil
        Low intake is associated with Dementia. Studies do show benefit of fish consumption on the risk of Dementia, cognitive decline, or MRI white matter abnormalities.
    • Active Lifestyle
    Dr. Bunch also pointed out that patients with more active lifestyles have lower risks of Dementia and cognitive decline.

    Drugs
    Dr. Bunch also discussed various Pharmacologic Therapies used to prevent Dementia:
    • Antihypertensive Agents
    Unclear role in prevention, particularly with onset of cognitive decline.
    • Cholinesterase Inhibitors
    Long-term use with onset of cognitive decline mildly improves cognitive function compared to placebo.
    • Hormone Therapy
    No benefit found.
    • NSAIDS
    Lower levels of amyloidogenic Abeta42 protein. Mixed results in clinical trials. One terminated early due to higher risk of heart attack.
    • Statins
    Retrospective data suggest lower risk of Dementia. Prospective trials are mixed with some suggesting there is a higher risk of Dementia with statin therapy.

Conclusions
    • A-Fib was significantly associated with all types of dementia, particularly in the younger group (under 70 years of age). Patients with A-Fib have higher rates of Dementia compared to those without and have worse outcomes.
    • Early intervention, such as A-Fib ablation, may improve long-term cognitive outcomes and reduce the risk of Dementia to that of patients with no history of A-Fib.
    (See also previous studies from the Intermountain Medical Center:
A-Fib Patients at Risk of Dementia
Ablation of A-Fib Reduces Risk of Alzheimer's and Dementia
A-Fib Patients at Greater Risk of Developing Alzheimer's )

FEBRUARY 10, 2011
    New story added to the Personal Experiences section of A-Fib.com: Alcohol Addiction Causes A-Fib. Cardioversion, then A-Fib Ablation by Dr. Mazur at the Un. of Iowa

FEBRUARY 10, 2011
    New question answered in the FAQs section:
"I was hospitalized with A-Fib. My heart beat was very irregular, but it never went above 100 (my normal resting heart beat ranges from 46-54 because I exercise a lot). Is this different physiologically from what most people seem to have? Should the treatment or prevention be any different?" (Thanks to Frank Boyle for this question.)
    It’s not at all unusual for athletes and people in good shape to have a relatively low A-Fib heart rate. When in A-Fib your heart rate may jump from 50 to 100. It’s still bad for you, as you probably felt. But it’s not as bad or dangerous as someone with a really high rate like 200+. (Those kind of high rates can strain the heart, drastically reduce circulation, and can even kill you. People experiencing those kinds of high A-Fib heart rates need to go to an Emergency room ASAP so that doctors can lower their heart rate and/or get them out of A-Fib.)
    You need to be careful about taking most Rate Control and some Antiarrhythmic meds which will lower your heart rate. You can't afford to have your heart rate go any lower. Otherwise you might need a pacemaker to get you out of a too slow heart rate (Bradycardia).
    And be sure you tell doctors, ER, and hospital personnel that you have a naturally low heart rate. Otherwise they will conclude you have Bradycardia and give you a pacemaker.

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

FEBRUARY 6, 2011
    Boston A-Fib Symposium 2011 continued, part 6:

Dr. Kowey's Statement about Ablation
(Due to bad weather the author's original flight was cancelled. One presentation missed was a debate by Dr. Peter Kowey of Lankenau Hospital, Wynnewood, PA and Dr. Eric Prystowsky of The Care Group, Indianapolis, IN about the merits and proposed features of the SAFARI registry [the Safety of Atrial Fibrillation Registry Initiative]. [SAFARI is a program currently in the planning stages to establish a national registry for A-Fib ablation.]
    Dr. Kowey issued a remarkable Disclosure statement which is quoted here:
    "Dr. Kowey doesn't perform AF ablations, but does refer patients occasionally, and usually under duress.
    Dr. Kowey would have an AF ablation is he were half dead but awake enough to choose the ablationist.
    Dr. Kowey would enthusiastically recommend AF ablation for plaintiff malpractice attorneys---especially those who advertise for amiodarone patients on billboards."
    Dr. Kowey's Disclosure statement also said that he is a consultant, speaker and grantee for over 20 pharmaceutical companies.
    The author regrets not being able to report on what was probably a very interesting, lively debate.)

Pulmonary Vein Isolation Alone for Long Standing Persistent A-Fib---Dr. Marchlinski
(In another surprising presentation,) Dr. Francis Marchlinski of the Un. of Pennsylvania said that his institution's protocol for ablating long standing persistent A-Fib does not include CFAE ablation, Mitral Annular and Left Atrium roof lines, and Coronary Sinus Isolation. (These are considered important steps in other center's protocols for ablating persistent A-Fib. See Stepwise Approaches for Chronic A-Fib.)
(Author's Comment: Patients with chronic A-Fib may want to be aware that at this time (January 2011) Dr. Marchlinski doesn't use the stepwise approach that others use, because he has not found the results to be significantly better.)

FEBRUARY 5, 2011
Boston A-Fib Symposium 2011 continued, part 5:
HYBRID ABLATION (COMBINING SURGERY WITH CATHETER ABLATION) FOR PERSISTENT A-FIB

Surgeons and EPs Compliment Each Other's Skills
    Dr. James Edgerton of Cardiovascular Specialty Associates of North Texas made some interesting comments about Surgeons and EPs (Electrophysiologists). Surgeons excel at making lesion lines. The smooth outside surface of the heart lends itself to this, and the surgeon's tools are designed for linear ablation. They can see the lines they make and breaks in the lines. While EPs excel at "spot welding." Catheter tips are punctate by design and can slip off of the uneven surfaces inside the heart.
    If epicardial (inside the heart) ablation fails, it is because it doesn't penetrate the endocardium. If endocardial (outside the heart) ablation fails, it is because it doesn't penetrate to the epicardium. Together these techniques complement each other.
    If surgeons put a line on the heart, they ought to have a mechanism to prove it is transmural or at least has acute conduction block. Surgeons have difficulty mapping epicardial lesions for several reasons:
    • Pericardial attachments inhibit free movement of a mapping probe.
    • Surgical mapping tools are homemade or (at best) first generation.
    • Surgeons aren't formally trained in mapping techniques.
While EPs can move freely around the inside of the heart, have mature mapping technology, and are formally trained in these techniques.

The "Hybrid" Combined Surgery/Catheter Ablation
    Dr. Edgerton described the "Hybrid" combined surgery/catheter ablation procedure which is similar to the "Convergent" Ablation Procedure demonstrated by Dr. Natale in the Satellite Case studies in that a surgeon and an EP work on the same patient.
    The surgeon, using a bipolar catheter, isolates the Pulmonary veins with encircling lesions, boxes off the posterior atrium wall, makes a connecting lesion to the base of the Left Atrial Appendage, then starts a lesion line down towards the Mitral Annulus which the EP will then finish from the inside of the heart. (Surgeons risk damaging the Circumflex Coronary if they were to continue the lesion line down towards the Mitral Annulus). The surgeon will also encircle and isolate the Superior Vena Cava with less risk of damaging the Phrenic Nerve than with catheter ablation. They simply lift the Phrenic Nerve out of the way before ablating. Surgeons can fully divide the Ligament of Marshall, if necessary. If Ganglionated Plexi are part of the operation, they are targeted and ablated.
    The EP from inside the heart then completes the line started by the surgeon, does a Caviotricuspid Isthmus line in the right atrium (which current surgery can't currently access), ablates within the Coronary Sinus (which isn't possible for surgery without significant risk of bleeding), uses mapping to find and ablate Flutter and CAFEs, and checks for entrance and exit block on all lesions. If part of the operation, they will also check the Ganglionated Plexi lesions.

Convergent Procedure Ablation Lines as done by Dr. Andy Kiser of ACATI. The blue lines are done by the surgeon, the green lines by the EP.

    Unlike a regular Mini-Maze operation, the patient must be on warfarin for 90 days after the operation.
    Dr. Edgerton's center has only done 5 patients so far. Five other centers are doing this "Hybrid" Ablation, but there is very little data available right now.
    Dr. Edgerton does not normally do Paroxysmal (Occasional) A-Fib cases. "I think they are very well treated with catheter ablation."

Competition or Collaboration between Surgeons and EPs
    Dr. Edgerton described an associate who by using direct patient marketing, evening seminars, etc. "does up to 400 inadequate (A-Fib operations) a year fully sidestepping cardiology and electrophysiology. Although you can get a lot of patients like that, I condemn it. It fully damages the collaborative approach."
    Dr. Edgerton, in contrast, believes in working with a fully trained EP. EPs are his best supporters. He depends on EPs for cases. Every patient he has ever operated on had been turned down for a catheter ablation.
    But he acknowledges that in other parts of the country EPs may see Surgeons as competitors for the same patient base and may be concerned about a loss of revenue. Or there may be ego involved, "I can fix anything." Or EPs may be concerned about a loss of quality control by sending patients to someone not formally trained in the field.
    But the Hybrid Ablation answers all these concerns and is the ultimate in collaboration. The EP is right there during the procedure, he has not lost control of the quality or direction of the care of his patient. Dr. Edgerton gave the example of the Medical College of Virginia where Dr. Ellenbogen was the driving force in starting the surgical program working with catheter ablation (but not a Hybrid approach---patients are directed to either catheter ablation or surgery depending on their individual needs). Volumes of both the catheter ablation and surgical programs increased. Patients flocked to a center that has multi-modal therapy available.

Practical Problems
    Dr. Edgerton discussed some of the practical problems associated with the Hybrid Ablation:
    • Work Flow/Down Time Issues.
    How do you avoid down time when either the Surgeon or EP is waiting for the other to finish, or the problem of an EP lab or operating room not being used while the EP and Surgeon are working together? One solution is predictable operating times or starting the surgery early in the morning. But minimizing Surgeon down time is more difficult in a Hybrid Ablation.
    (Dr. Edgerton described how the original Hybrid Ablation procedure was to leave all Surgical wounds open while the EP performed the catheter ablation. The Left Atrial Appendage would be amputated only after all catheters were removed. Now the Surgeon finishes all his work before the EP starts.)
    • Stages or Simultaneous?
    It's possible to do Hybrid Ablation Surgery on a patient, then three months later do a catheter ablation. Advantages are that the Surgeon and the EP get to work in their home environment, there are no work flow issues, and maybe some patients won't need an catheter ablation. Disadvantages are that patients are likely to refuse the second stage, because they feel better and because of the added expense. And two anesthesias increases the complication rate for patients. (One would expect the actual degree of collaboration between Surgeon and EP would be considerably less if they did their work three months apart.)
    Dr. Edgerton prefers the simultaneous approach where both the Surgeon and the EP take their best shot working together on a patient, the patient has a single anesthetic, and presumably a shorter hospital stay.
    • Reimbursement Problems
    In the US system, if you take a patient to the OR and to the EP lab in the same hospital stay, only one will be paid for.

    (Author's Note: From this patient's perspective, the "Hybrid" and "Convergent" ablations seem very similar. The "Hybrid" Ablation seems more Surgeon driven, while the "Convergent" Ablation seems more EP driven.
    Surgeons working with EPs to improve the results of Mini-Maze operations seem to have the potential to improve the results of Mini-Maze surgeries for A-Fib patients.
    But patients should consider that the surgery, though called "minimally invasive," is still major heart surgery. It is invasive, traumatic, complicated, requires considerable surgical skills and experience, and is potentially risky. And added to this are the low but real risks of a catheter ablation. Combining these two levels of risk is probably more dangerous than the sum of the parts.
    Which patients should consider a "Hybrid" Ablation? Possibly someone who has failed one or two catheter ablations, or who is morbidly obese (which causes problems for current catheter imaging systems). But it will take more time and data to determine if the "Hybrid" Ablation is better and more effective than current advanced catheter ablation strategies.)

February 1, 2011
Overview of the Boston A-Fib Symposium 2011 continued, part 4:
MRI (MAGNETIC RESONANT IMAGING) APPLIED TO A-FIB
    Dr. Nassir Marrouche of the Un. of Utah described the data enhancement (also called "delayed-enhancement") MRI process which uses a metallic Gadolinium contrast dye to see in 3D and identify collagen fibrotic areas in the heart. The Gadolinium contrast dye penetrates and stays longer in dead fibrotic tissue, then washes out later. MRI imaging does not expose patients to ionizing radiation.
    Dr. Marrouche uses MRI to "personalize A-Fib treatment." He separates A-Fib patients by their degree of fibrosis into what he calls four "stages:"
    1. A "Utah 1" patient has little scarring or fibrosis.
    2. A "Utah 2" patient has 5% to 20% of scarring or fibrosis.
    3. A "Utah 3" patient has 20% to 35% scarring or fibrosis.
    4. A "Utah 4" patient has a lot of scarring or fibrosis, over 35%
    When considering other factors such as the duration of A-Fib, size of the left atrium, how symptomatic a patient is, whether they are paroxysmal, persistent, long-standing persistent or permanent, what counts---what's key for success, according to Dr. Marrouche, is the amount of fibrosis in the left atrium.²³⁰
    The degree of fibrosis correlates with the danger of stroke. For example a 20%+ degree of fibrosis (stages Utah 3 and 4) indicates a threefold increased risk of stroke. These patients should be kept on Coumadin or protected by devices such as the Watchman.
    Utah Stages 1 and 2 usually only need a PVI to terminate A-Fib. While Utah Stage 3 requires more extensive ablation. Stage 4 is what Dr. Marrouche calls 'the point of no return.'²³⁰ Success rates for catheter ablation are only 3%-4% after one year at Dr. Marrouche's facility.²³⁰    20-30 minutes after an ablation, Dr. Marrouche also uses MRI to check lesion accuracy and safety. If there are problems, the patient can be wheeled back into the EP lab to continue the ablation.
    Dr. Marrouche is starting the DECAAF trail (Determinant of Catheter Ablation of Atrial Fibrillation using Delayed-Enhancement MRI) at 24 centers around the world. Each patient will have an MRI and be separated into stages before an ablation, then 3 months later will get another MRI to look at the amount of lesions. It's possible that someone in A-Fib for 6 months could have more scarring/fibrosis than someone in A-Fib for 6 years.

    In the question and answer session following Dr. Marrouche's presentation, Dr. Vivek Reddy from Mount Sinai, NY made the following observation, "We should be cautious about equating scarring (fibrosis) with abnormal tissue that should be ablated. There is a discordance between voltage that correlates with scar tissue and CFAEs."

    Dr. Pierre Jaïs from the French Bordeaux group, in a study that was developed in collaboration with Dr. Marrouche, addressed this same topic---how do MRI delayed-enhancements (fibrosis) correlate with electrogram characteristics of A-Fib? "We expected to see more fractionation in fibrotic areas, but found just the opposite." He showed a slide of a patient in persistent A-Fib for 18 months. The patient's posterior left atrium wall had large delayed-enhancement areas (fibrosis), but no complex fractionated potentials at all. He found this in the vast majority of patients. It was more frequent to find CFAEs in areas of no delayed-enhancement. There was only a 6% overlap of areas of delayed-enhancement and CFAEs, which was an inverse correlation.

    (Author's Observations: It must be devastating to sit in Dr. Marrouche's office and be told you are "past the point of no return," you are doomed to life in A-Fib because you have too much fibrosis in your heart. What about all the Chronic A-Fib patients who have been made A-Fib free? Dr. Jaïs' long-term persistent A-Fib patients, particularly those with underlying heart disease, have a lot of fibrosis but often are made A-Fib free. However, we don't know if those Chronic patients had more than 35% fibrosis. But one would expect that many did.
    A 3%-4% success rate in cases of over 35% fibrosis (Utah Stage 4) is dismal. Could it be that they are targeting for ablation fibrosis areas which research shows do not generate A-Fib signals? One wouldn't normally expect to see a lot of electrical activity in fibrous tissue. Why not use established protocols for ablating Chronic A-Fib in Utah Stage 4 patients?
    What then are the real benefits for patients in using MRI to determine levels of fibrosis? It certainly would be a help for doctors to see before an ablation how difficult a case might be. But doctors currently get this information from such factors as the duration of A-Fib, size of the left atrium, how symptomatic a patient is, and whether they are paroxysmal, persistent, long-standing persistent or permanent.
    Identifying and locating fibrosis areas in the heart doesn't seem to be much of a help in the ablation procedure.
    Level of fibrosis does correlate with the danger of stroke and could be a good tool to identify and treat patients with more risk of stroke. It might be an addition to the CHADS2 and CHA2DS2-VASc scores but probably wouldn't replace them.
    An MRI might be useful in checking the quality of ablations, but it seems somewhat cumbersome to move a patient back and forth from the EP lab to the MRI room.)

JANUARY 27, 2011
Overview of the Boston A-Fib Symposium 2011 continued:
USING CFAEs IN ABLATING PERSISTENT A-FIB
    CFAEs are Complex Fractionated Atrial Electrograms (an electrogram is a picture of the electrical activity of the heart as sensed by a pacemaker or catheter in the heart). They are low voltage electrical signals with very short cycle lengths used to identify areas in the heart that need to be ablated. See Complex Fractionated Atrial Electrograms.

    Dr. Jose Jalife of the Un. of Michigan showed how CFAEs can have different forms of waveform propagation, such as Collision, Block, Pivot Point and Slow Conduction.

    Dr. Mauritz Allessie of Maastricht Un. in the Netherlands described his "double layer hypothesis"---that in cases of persistent A-Fib two layers of dissociated fibrillation waves mutually feed each other eternally. (Author's Note: Dr. Allessie's description of a new mechanism to explain how A-Fib works in persistent A-Fib patients is a potential game changer.)
    Dr. Allessie had the following warning about using CFAEs, "If you see an area of continuous electrical activity, do not immediately jump to the conclusion that you have found an area of A-Fib nest or driver."

    Dr. Sanjiv M. Narayan of the Un. of California, San Diego, working with the French Bordeaux group, described five different types of CFAEs. He hypothesized that Type I CFAEs (rapid localized activity with low amplitude, rapid rate, and narrow spectral organizational index) might indicate localized rapid reentry and be clear cases of "Focal" A-Fib that should be ablated. (MAP stands for Monophasic Action Potential catheter mapping.)


    Dr. Shin-Ann Chen of Taipei Veteran's General Hospital, Taiwan, described how in cases of long standing Persistent A-Fib there are so many CFAEs that it is difficult to ablate them all (his facility has a guideline to limit CFAE ablations to only three sites). He proposes a "Similarity Index" or "New Regularity Index" to identify CFAE sites to ablate. Using non-linear analysis he identifies CFAE sites similar in consistency of interval, electrogram morphology, and voltage amplitude in a particular patient. Ablating these sites results in more successful termination of A-Fib than using other factors such as dominant frequency analysis, fractionated interval analysis, or harmonic index.

    Dr. David Wilber of Loyola Un., Chicago, explained how current observational systems of identifying CFAEs to ablate are subjective and non-reproducible. However, "automated electrogram analysis provides a rapid, objective, and systematic method of identifying sites with CAFEs" to be ablated. He discussed three different algorithms being tested:
    1. Counting peak to peak intervals
    2. Counting short coupling intervals between discrete & complex fractionated electrograms
    3. Looking at continuous CAFEs
    "But we are still searching for the optimal criteria to identify the most useful characteristics for successful ablation."
    He also described how pharmaceutical intervention---using the antiarrhythmic drug ibutilide (Corvert) shrinks the number of CFAE sites by prolonging cycle length and decreasing some of the short cycle lengths.

    Dr. Moussa Mansour of Massachusetts General Hospital in Boston cited several studies indicating that ablating CAFEs is an effective strategy for treating persistent A-Fib. CFAEs may identify A-Fib drivers, may indicate a nearby autonomic ganglionated plexus, or may identify areas of slow conduction for a local reentrant circuit.
    But current definitions of CFAEs and procedural end points are not uniform. And CFAE areas may be extensive in persistent A-Fib, covering as much as 86% of left atrium sites and requiring extensive ablation.
    Dr. Mansour discussed several strategies to differentiate "Active" CFAEs from "Passive" (areas that don't drive or trigger A-Fib).
    1. Pharmacologic intervention reduces the number of CFAE sites. But we don't know if this affects only the "passive" CFAEs or the "active" CFAEs as well.
    2. Monophasic Action Potential catheters can identify "Far-field" signals which don't affect A-Fib.
    3. Limiting ablation to Continuous Electrical Activity CFAEs. The Bordeaux group identifies areas with 90% fractionation which may indicate an A-Fib driver
    4. Using a multi-spine catheter for mapping, the Bordeaux group identifies passive activation where a wave simply passes through a field of mapping, whereas Centrifugal activation can represent a driver for A-Fib.

5. Massachusetts General uses electrical anatomical mapping to identify activation patterns. They found three basic patterns: Colliding Waves (22%), Passive Activation (48%), and Pivot Points (30%). Pivot Points may indicate drivers for A-Fib.

(Author's Observations: The above studies may represent advances in both the understanding and use of CFAEs in ablating persistent A-Fib. Doctors are much closer to finding a definitive strategy for using CFAEs effectively.)

January 21, 2011
Overview of the Boston A-Fib Symposium 2011 continued:

SATELLITE CASE TRANSMISSIONS
One of the highlights of the Boston A-Fib Symposium is always the Live Case Transmission of A-Fib procedures from around the world. This year six different cases were presented, four of them pre-taped. (Previous Symposiums only had two.)

16th ANNUAL BOSTON ATRIAL FIBRILLATION SYMPOSIUM, January 13-15, 2011. “Atrial Fibrillation: Mechanisms and New Directions in Therapy.”

The overall mood of the 16^th Boston A-Fib Symposium was certainly influenced by the winter blizzards which cancelled many flights into Boston (including the author’s). “Let’s make it work” seemed to be the mantra as the organizers moved presenters who did arrive to take the place of those who were delayed. Talks scheduled for Friday were moved to Thursday morning, while Friday’s sessions started a half hour early so that all speakers could give their talks.

To the author, this Symposium’s signature or most prominent topic of interest was Recurrence/Reconduction/Durability of catheter ablations. The second most often discussed topic was dabigatran (recently approved by the FDA) and other blood thinners as alternatives to warfarin.

                Though Pulmonary Vein Ablation (Isolation) (and the Maze-type operations) are currently the only hope of a long lasting fix to make patients A-Fib free, there is increasing evidence that a successful PVA(I) isn’t always permanent.
                Dr. Karl-Heinz Kuck from St. George Hospital in Hamburg, Germany described early studies which showed recurrence/reconnection within the first years after an ablation, but no or little recurrence after that. However, at his facility he followed for five years 161 patients who were ablated in 2003-4 and found that there was a steady progressive recurrence rate over time which he hypothesized will continue after five years. He concluded that, “we may not (permanently) cure patients with A-Fib.”
             Of his patients fixed after a single ablation, 60% remained A-Fib free after five years.
            Dr. Kuck also cited a recent Bordeaux study of patients ablated in 2001-2. Of patients who had a single ablation, only 30% were A-Fib free after five years. Of those who had two ablations, 63% were A-Fib free after five years. But most patients had two ablations. There was an annual 8.9% recurrence rate over time.) [It should be noted that ablation techniques have changed and improved significantly since those early days of catheter ablation].)
http://www.theheart.org/article/1168671.do

Recurrence Due to Reconnected Pulmonary Veins
                Dr. Francis Marchlinski of the Un. of Pennsylvania described how in his experience A-Fib recurrence after a PVI is often due to reconnected Pulmonary Veins. “Since PV reconnection is the rule, and not all patients even attempt repeat procedures, then we may be underestimating true efficacy.”
              (Author’s Note: In private conversations and in the question and answer sessions, doctors were very concerned about the durability of RF catheter ablations. In a successful ablation doctors isolate the pulmonary veins and check for entrance and exit block---that no A-Fib signals are getting through the lesion lines that isolate the veins. But current ablation techniques all too often create lesions that don’t last.)

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

WATERSHED YEAR FOR A-FIB PATIENTS (AND DOCTORS)---DABIGATRAN APPROVED
             Dr. Daniel Singer of Massachusetts General and Dr. Jeffrey Weitz of McMaster University, Canada described the major improvements in stroke prevention now available to patients. Not only did the FDA approve the new anticoagulant dabigatran (Pradaxa), but other possible replacements for warfarin made major advances in the approval process---rivaroxaban, apixaban, and edoxaban.
            They described some of the advantages of dabigatran over warfarin:
            1. Warfarin requires crucial monitoring and requires on average 17 INR tests/year, while dabigatran only needs to be taken twice a day to be effective.
            2. Warfarin often interacts with and is affected by other meds and diet, while dabigatran doesn't seem to have a great deal of interaction problems.
            3. It takes four days for warfarin to be effective or to be eliminated from the body, but dabigatran can be effective in 30 minutes to two hours.²²⁶
                4. Warfarin can cause bleeding problems, but dabigatran in clinical trials produced a 60% reduction in intracranial bleeds compared to warfarin.²²⁶
            5. Warfarin is affected by genetics. People starting warfarin need to be tested for variations in the CYP2C9 and VKORC1 genes, while this isn't necessary when starting dabigatran.)

Aspirin Therapy
                According to Dr. Singer, warfarin reverses the risk of stroke in A-Fib, but aspirin doesn’t. In three clinical trials using dosages of 75 mg (baby aspirin) and 325 mg, aspirin produced a Relative Risk Factor of 21% (0-38%), but had no significant impact on severe/fatal stroke.
            (Author's Note: People at low risk of an A-Fib stroke (CHADS2 score of 0-1) are often put on aspirin antiplatelet therapy. But we know that aspirin is not very effective in preventing an A-Fib stroke. Dabigatran, however, would give real protection from an A-Fib stroke. In the clinical trials dabigatran provided a 34% reduction in stroke compared to warfarin.²²⁶
            The author predicts that dabigatran will replace aspirin for patients at low risk of an A-Fib stroke.)

(More to follow.)

DECEMBER 24, 2010
AMIODARONE---toxic levels?
    How much amiodarone can be suspected to produce toxic effects? This was added to FAQs question about amiodarone.
    The recommended maintenance dose of amiodarone is 200 mg/day.²²⁵A possible toxic level of amiodarone may be 400 mg daily for more than two months, or a low dose for more than two years.225

DECEMBER 20, 2010
    The FDA approved the first cryoablation balloon catheter for A-Fib---the Arctic Front system (Medtronic, Minneapolis, MN). This is a major medical breakthrough in treating A-Fib.                Cryoballoon ablation appears to be safer, faster and easier than RF. The cryoballoon can isolate a pulmonary vein opening in as little as one freeze (about 10 minutes per vein), while an RF ablation requires ablating one spot at a time. Also, the frozen balloon sticks to the PV opening, which keeps the catheter stable during the ablation. In a study of the clinical trial (STOP AF), there were no strokes, no pulmonary vein stenosis, no esophageal injury, and no coronary artery injury as sometimes occurs with RF ablation (RF ablations typically have a major complication rate of around 4%).
    In the clinical trial 69.9% of patients treated with the Arctic Front Cryoballoon catheter were free from A-Fib at one year, compared to only 7.3% of patients on meds only.
    See Cryoballoon Safer than RF, Cryoballoon and RF Ablation, CryoBalloon & RF Ablation---the future of A-Fib treatment, and Dr. Kerwin's explanation of Cryo Ablation.
    (The author predicts that Cryoballoon ablation, perhaps combined with RF, will become the treatment of choice for Pulmonary Vein Ablations.)

http://www.theheart.org/article/1166735.do?utm_campaign=newsletter&utm_medium=email&utm_source=20101222_EN_Heartwire

DECEMBER 22, 2010
    New Personal Experience story: From Shanghai to Bordeaux---a very difficult case requiring two ablations

DECEMBER 17, 2010
   In the FAQs section question #28 "Which is the best A-Fib treatment for me?" a new A-Fib condition and options were added.
"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 your Chronic A-Fib. You will have to be on blood thinners or have a Watchman device installed to keep from having an A-Fib stroke. You will probably have to take rate control meds to keep your heart from beating too fast. Your heart isn't pumping out properly, but you can compensate to some extent by exercise. You may be able to lead a close to normal life in silent Chronic A-Fib. It's hard to justify the effort and risk necessary to fix Chronic A-Fib if you have no A-Fib symptoms.
    Chronic A-Fib is harder to fix and often requires at least two ablations. An unintended consequence of a successful ablation for Chronic A-Fib is your A-Fib may be improved so that you are only Paroxysmal (occasional). But Paroxysmal A-Fib may be more debilitating and troublesome than being in Chronic A-Fib. At least in Chronic A-Fib you don't have to worry about an A-Fib attack.
    A Cox Radial Maze to fix Chronic A-Fib is open heart surgery which is very traumatic and risky. It's hard to justify open heart surgery if you're feeling OK.
    Another factor to consider is your age. If you're 40 years old, it's probably worth the effort to get your silent Chronic A-Fib fixed. Chronic A-Fib over time will probably damage your heart, brain, and other organs. But if you're in your 70s, you can probably live the rest of your life in a satisfactory, fulfilling manner even with silent Chronic A-Fib.
    However, having had A-Fib, the author knows how wonderful it is to be in normal sinus rhythm. Even though you have silent Chronic A-Fib and in general feel OK, you may want and need to get rid of your Chronic A-Fib. Most doctors understand this need to have a heart that beats normally and will work with you, as long as you understand the risks and challenges. See the options under I Have Chronic A-Fib.

DECEMBER 14, 2010
    CLEVELAND CLINIC SECOND OPINION PROGRAM
    The Cleveland Clinic has developed an online consulting service that A-Fib patients can use. They will "review your individual situation (including medical records and test results), answer your questions and provide you with a comprehensive report - with treatment options or alternatives, as well as recommendations regarding your future care needs." The cost is less than $600. There is a caveat, "Availability of online medical second opinion varies by state of residence."
    (If anyone uses this service, could you please tell us what you think of it? Thanks.)
http://eclevelandclinic.org/myconsult
    (Thanks to Jerome Jacobi for calling our attention to this service.)

NOVEMBER 29, 2010
    New section added to the Overview about what A-Fib sounds like.
    If you'd like to listen to how a heart may sound when in A-Fib, click on this web site. http://filer.case.edu/~dck3/heart/sounds/af.wav. Notice how irregular the ventricular beats sound. You are not hearing the fibrillation beats in the atria which can't be heard through a normal stethoscope. For comparison purposes, here is a web site with a normal heart beat. http://www.youtube.com/watch?v=i9ILX2a1dS8&feature=related.) (Thanks to Nancy Hansen for the idea of including the sound of A-Fib in the Overview section of A-Fib.com.)

NOVEMBER 22, 2010
    New question answered in the FAQs section:
     "I definitely have A-Flutter and possibly A-Fib as well. They want to do a Flutter-only ablation on me. Will that help me?"
    Probably not.
    If you have both A-Fib and A-Flutter and have only a Flutter (right atrium) ablation, it's estimated the success rate for curing A-Fib is only between 5 and 10 %.²¹⁹ You're usually wasting your time and undergoing needless risk to do a Flutter-only ablation when you also have A-Fib.
    But what if you have Atrial Flutter and not A-Fib? In this author's opinion, an A-Fib ablation in the left atrium should normally be done at the same time as a Flutter ablation. (A Flutter ablation in the right atrium is relatively simple and doesn't take much time.) Some Flutter may originate in the left atrium, or the Flutter may mask A-Fib which may appear later after a successful Flutter ablation "As many as half of all patients ablated for Flutter may later develop A-Fib."²¹⁹A research study atBall Memorial Hospital suggests that anyone with only A-Flutter would be better served by both a Flutter and an A-Fib ablation at the same time.²¹⁹ See Flutter Ablation Should Be Combined With A-Fib Ablation.

NOVEMBER 15, 2010
rIVAROXABAN another possible replacement for WARFARIN
Rivaroxaban (brand name Xarelto by Bayer/Johnson & Johnson) tested well as a replacement for the blood thinner warfarin. Both rivaroxaban and warfarin block the action of vitamin-K dependent proteins called clotting factors, but rivaroxaban targets a specific clotting factor called Xa.

NOVEMBER 3, 2010
DABIGATRAN NOW AVAILABLE IN PHARMACIES
    Dabigatran (brand name Pradaxa by Boehringer Ingelheim) will be priced at a "wholesale-acquisition" cost of $6.75/day.
    According to Dr. Michael Ezekowitz, switching patients from Coumadin is relatively easy. If the INR (international normalized ratio) is 2 or less, you can switch the patient immediately to dabigatran. It only takes 30 minutes to two hours for it to become effective. Dabigatran produces a 34% reduction in stroke, a 60% reduction in intracranial bleeds, and fewer bleeds in general.
    The only patients who shouldn't take dabigatran are those with kidney problems (creatinine clearance of less than 15 which is close to needing dialysis), and patients with mechanical heart valves (not part of the original RE-LY trial).

http://www.theheart.org/article/1142899.do

OCTOBER 31, 2010
aNTICOAGULANTS AND ANTIPLATELETS DON'T MIX
    If someone is taking an anticoagulant like warfarin to prevent A-Fib stroke, wouldn't it be more effective to also take an antiplatelet like aspirin as well since they work differently? That doesn't seem to be the case.
    A Danish study, reported in Hans Larson's October The AFIB Report, indicates that combining anticoagulant and antiplatelet meds in the same patient is associated with a substantially higher risk of fatal or non-fatal internal bleeding. And there was no indication that combining warfarin with an antiplatelet (aspirin, clopidogrel, or both) reduced the risk of ischemic stroke.

http://www.afibbers.org/afib103jh.pdf
Larson, Hans. The AFIB Report. "Anticoagulation-Dangerous combinations" Number 103, October, 2010. p. 8.
Hansen, ML, et al. "Risk of bleeding with single, dual, or triple therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation." Archives of Internal Medicine, Vol. 170, No. 16, September 13, 2010, pp. 1433-41.

OCTOBER 30, 2010
fLUTTER aBLATION should be combined with a-fib ablation
    Hans Larson, in his October The AFIB Report, points out that trying to cure A-Fib with only a right atrium Flutter ablation "is usually fruitless with a success rate somewhere between 5 and 10%."
    But what if someone only has Atrial Flutter and not A-Fib? Since a Flutter ablation in the right atrium is relatively simple and doesn't take much time, should an A-Fib ablation in the left atrium be done at the same time? Some Flutter may originate in the left atrium, or the Flutter may mask A-Fib which may appear later after a successful Flutter ablation? "As many as half of all patients ablated for Flutter may later develop A-Fib."
    Researchers at Ball Memorial Hospital in a small study of patients with lone right atrium flutter gave some patients a right atrium Flutter ablation only, while others received both a Flutter and an A-Fib ablation at the same time.
    After a 16-month follow-up, 87% of the group that had received both a Flutter and an A-Fib ablation were free of any arrhythmia without the use of any medication. But only 44% of the Flutter-only group were so lucky. 36% developed paroxysmal A-Fib and 20% developed persistent A-Fib. The researchers concluded that adding Pulmonary Vein Isolation ablation to Flutter ablation for lone atrial flutter provides better long-term freedom from arrhythmias than just performing a Flutter ablation by itself.
    (Editor's Comments: If someone recommends you get a Flutter-only ablation, you should probably get a second opinion. If you have A-Fib and A-Flutter, you are probably wasting your time on a right atrium Flutter-only ablation.
    If you only have documented Atrial Flutter, you should still get a second opinion. Some Flutter does originate in the left atrium, or the Flutter may mask A-Fib which can often appear later. This Ball Memorial Hospital study suggests that anyone with only Flutter would be better served by both a Flutter and an A-Fib ablation at the same time.)

http://www.afibbers.org/afib103jh.pdf
Larson, Hans. The AFIB Report. "Acupuncture: An effective antiarrhythmic?" Number 103, October, 2010. p. 6.
Navarrete, A. et al. "Ablation of atrial fibrillation at the time of cavotricuspid isthmus ablation in patients with atrial flutter without documented atrial fibrillation derives a better long-term benefit." Journal of Cardiovascular Electrophysiology, July 19, 2010 (Epub ahead of print)

OCTOBER 29, 2010
    Acupuncture Helps A-Fib---Specific Acupuncture Sites Identified
    Hans Larson, in his October The AFIB Report, states that Italian researchers found acupuncture effective in preventing A-Fib in persistent A-Fib patients who had just undergone successful cardioversion.
    The acupuncture points used in the Italian clinical trial were:
    1. Neiguan (PC-6)
    2. Shenmen (HT-7)
    3. Xinshu (BL-15)
    Acupuncture at the Neiguan and Xinshu points help modulate and stabilize the autonomic nervous system. Stimulation of the Shenmen point has a calming and sedative effect on cardiac excitability. Patients received 10 weekly acupuncture sessions.
    The article also includes two stories of patients whose A-Fib was eliminated primarily by acupuncture:
    http://www.afibbers.org/resources/journeys/Craig.pdf
    http://www.afibbers.org/resources/journeys/Girskis.pdf
    (Editor's Comment: As Hans Larson points out, now that we know the exact points to be stimulated, why not use acupuncture for Paroxysmal A-Fib as well?)

http://www.afibbers.org/afib103jh.pdf
Larson, Hans. The AFIB Report. "Acupuncture: An effective antiarrhythmic?" Number 103, October, 2010. p. 5.
Lomuscio, A et al. "Efficacy of acupuncture in preventing atrial fibrillation recurrences after electrical cardioversion." Journal of Cardiovascular Electrophysiology, August 30, 2010 (Epub ahead of print)


OCTOBER 28, 2010
Vigorous Exercise and A-Fib
    Some commentators have cited recent research on vigorous exercise to say it is associated with the development of A-Fib. "Vigorous exercise increases the risk of atrial fibrillation."²¹⁸ But a close examination of the observational study used to support this statement shows that A-Fib is associated only with men under 50 years of age who jogged/ran over four miles a day 5-7 times a week. This is a level of running usually associated only with elite athletes. Other types of vigorous exercise such as cycling, swimming or racquet sports were not associated with an increased risk of A-Fib.
    Why only elite male runners under 50? The authors of this study hypothesized that several factors might explain the increased risk of A-Fib in elite male runners under 50 years old.
    - left atrial enlargement
    - left ventricular hypertrophy
    - left ventricular dilation
    - an increase in parasympathetic tone (the most commonly cited factor)
"Jogging in particular results in greater enhancement of the parasympathetic nervous system compared to other exercise types." "Heightened parasympathetic tone has been associated with A-Fib onset in patients with structurally normal hearts; and in animal and human studies, parasympathetic stimulation frequently induces and maintains A-Fib, whereas vagal denervation prevents A-Fib."
    People over 50 years old have decreased parasympathetic activity and usually exercise less vigorously as they age.
    The authors of this study recognize the benefits of vigorous exercise for most people. "Exercise has multiple beneficial effects on cardiovascular health that may lower A-Fib risk." In particular, exercise lowers blood pressure, improves lipid profile and glucose control, and decreases risk of cardiovascular disease.
    (Editor's Comments: With the exception of elite male runners under 50 who run over four miles a day 5-7 times a week, vigorous exercise does not increase the risk of A-Fib, according to this study. Rather, vigorous exercise may lower A-Fib risk.)
Aizer, A. et al. "Relation of Vigorous Exercise to Risk of Atrial Fibrillation." The American Journal of Cardiology, Volume 103, Issue 11, Pages 1572-1577, June 1, 2009
http://www.ajconline.org/article/S0002-9149(09)00549-9/fulltext

OCTOBER 27, 2010
Steroids Reduce A-Fib Recurrence after an Ablation
     For A-Fib patients (as well as for EPs and Mini-Maze surgeons), the biggest frustration after an ablation or surgery is the recurrence of A-Fib. Even the most experienced A-Fib centers have unacceptably high rates of recurrence. This recurrence is often due to regrowth/re-connection of previously ablated areas (see Marchlinski "Regrowth/Reconnection of Ablated Areas"). http://www.a-fib.com/BostonA-FibSymposium2007.htm#ThirdandFourthPVIsolation/AblationProcedures
    Japanese researchers administered intravenous hydrocortisone to Paroxysmal A-Fib patients the day of their ablation, followed by oral prednisolone for three days after the ablation. (The hydrocortisone dosage was 2mg/kg which translates to approximately 750 mg for a 170 lb. person. The oral prednisolone dosage was 0.5mg/kg which translates to approximately 190 mg for a 170 lb person.)
    Within the first three days, 31% of individuals treated with a placebo had a recurrence of A-Fib, compared with only 7% of those treated with corticosteroids. Corticosteroid treatment did not decrease A-Fib recurrences between 4 and 30 days after ablation (A-Fib patients were not given corticosteroid treatment during these days). The A-Fib-free rate at 14 months post-ablation was greater in the corticosteroid group---85% versus 71% for the placebo group (a statistically significant difference [p=0.032), but not nearly as large as the first days' results).
    (Editor's Note: One wonders what would have happened if the oral prednisolone was continued for more than three days.)
    The researchers found that inflammation, highest body temperature, largest change in body temperature, maximum C-reactive-protein (CRP) levels, and change in CRP were lowest among patients with steroid therapy.
    (Editor's Note: All of the above are markers or signs of inflammation which some research links to A-Fib^.84 Steroids may work to reduce recurrence of A-Fib by lowering inflammation after a procedure. Steroid therapy, by reducing inflammation, may be a safe and effective method of reducing recurrence of A-Fib after an ablation. Steroid therapy after ablation may be a major medical breakthrough in the treatment of A-Fib..
    Even though this study is small (125 patients) and limited, A-Fib patients undergoing ablation and/or Mini-Maze surgery should receive steroid therapy, unless counter indicated. The steroid therapy should probably be continued for more than three days. Steroid therapy certainly seems to reduce the recurrence rate of A-Fib after ablation.)
(Thanks to David Holzman to calling our attention to this article.)

http://www.theheart.org/article/1139047.do
Koyama, T. et al. "Prevention of Atrial Fibrillation Recurrence With Corticosteroids After Radiofrequency Catheter Ablation." Journal of the American College of Cardiology, 2010; 56:1463-1472.

OCTOBER 26, 2010
Increased PR Interval a Red Flag for developing A-Fib

In the well-known Framingham Heart Study, people who had PR Intervals longer than 200 ms had twice the risk of developing A-Fib (as well as three times the risk of requiring a pacemaker and a 40% increased risk of death from all causes).

("PR Interval" is the time it takes for an electrical signal to spread from the upper chambers of the heart (the atria) to the lower chambers (the ventricles). A PR Interval of less than 200 microseconds (ms) is considered normal. A prolonged or increased PR Interval is known as "first-degree atrioventricular block (AVB)" when the PR interval exceeds 200 ms.)

(Editor's Note: A prolonged PR Interval may be a sign or marker for fibrosis, scarring, or other heart conduction problems that may lead to A-Fib. A routine EKG would show whether you have a prolonged PR Interval. If so, your doctor should check you periodically to make sure you aren't developing any progressive conduction block.)

http://www.theheart.org/article/981659.do

Cheng S. et al. "Long-term outcomes in individuals with prolonged PR interval or first-degree atrioventricular block." JAMA 2009;301:2571-2577.

This year voters in California will vote to legalize and tax cannabis (pot) which is already approved for medical use. Pot is widely used in the US and internationally.

In this article from Israel where pot is the most widely used illegal drug, the author observed that a 20-year-old male admitted to the hospital for A-Fib had no other apparent pathological cause of his A-Fib except "cannabis abuse." He recommends that young people admitted to the hospital for A-Fib be tested for cannabis abuse, and be counseled to stop cannabis drug abuse.

"Cannabis abuse is responsible for a wide range of pathologies, including atrial and ventricular arrhythmias, cognitive impairment, a rise in the prevalence of lung, head, and neck tumors, and an increase in the risk of ischemic cardiovascular events (strokes). Cannabis abuse can induce A-Fib in predisposed patients."

(Editor's Note: Please be advised that this is an observational study based on the author's experience and observations, rather than a clinical study of cannabis. Also, the term "cannabis abuse" is not defined. How much cannabis use would be considered "abuse?" Would any use of cannabis be considered "abuse?"

In spite of the above reservations, this article may be an important warning, particularly for young people. If you use pot and develop A-Fib [whatever your age], you may need to cut your use or stop using pot all together.

The original clinical trial for the Watchman device (PROTECT AF) was completed in 2009. However, doctors in the trial continue to insert the Watchman device and follow up on patients who have received it.

In new studies and updates, procedure time to insert the Watchman device was reduced, implant success was greater, and the proportion of patients who discontinued warfarin at 45 days was significantly increased. Device safety improved. Major bleeds, pericardial effusion, and device embolization dropped from a hazard ratio of 2.85 to 1.57. According to a study to be published by Dr. Vivek Reddy (Mount Sinai Medical Center), pericardial effusions for the most part occurred very early on, and rates tend to go down with more operator experience.

Dr. Joseph Rodes-Cabau (Quebec Heart and Lung Institute) called the results "really encouraging." He was particularly impressed by the reduction in ischemic strokes. "Most of the ischemic strokes in the device group occurred in the first 7 days." The rate of ischemic stroke over follow-up was "pretty low...The concept seems to be right---that thrombus (clot) formation in the left atrium is mostly in the Left Atrial Appendage, and that closing it will significantly reduce ischemic stroke."

An FDA advisory panel approved the Watchman device in a close 7-5 vote (PROTECT AF trial presented April, 2009). But the FDA has mandated a new trial of the Watchman device dubbed PREVAIL that will randomize 475 patients 2:1. In order to address several of the concerns raised during the advisory panel hearing, the trial will focus on enrolling patients with a CHADS2 score of 2 or higher or CHADS2 1 patients with existing heart disease. The last follow-up visit will be in September 2013, with the data to be submitted to the FDA one month later.

    One problem not addressed in current US trials is whether the Watchman device can be used in patients who can not tolerate warfarin at all. (In the original PROTECT AF study, patients who received the Watchman device also took warfarin for several weeks.) There is a higher risk of thrombus (clotting) in the first week after device implementation. A current study in Europe gives patients six months of Clopidogrel plus aspirin instead of warfarin. Though this study is ongoing, so far out of 64 patients there has been one serious pericardial effusion and no strokes or transient ischemic attacks.

    A surgical device for LAA occlusion, known as the AtriClip, has been FDA approved. It is usually used during a Mini-Maze or other heart operation rather than as a stand-alone operation. (Surgical devices tend to be more readily approved by the FDA than catheter devices.)

    (Editor's Note: The Watchman device is considered a low risk procedure with an even lower risk than a typical catheter ablation, since there is no ablation involved.
    "Pericardial effusion" refers to blood leaking from the heart into the pericardium, the sac surrounding the heart. This may occur when the Watchman device is inserted into the Left Atrial Appendage, and is less likely to happen with operator experience.
    "Device embolism" refers to clots that form on or are possibly stirred up by inserting the Watchman device. (There is a similar risk during catheter ablations.) However. after seven days this risk is eliminated. To prevent device embolisms, anticoagulants are administered during and after the Watchman is inserted.
    In the Editor's opinion, the payoff of a 90-95% reduction in A-Fib strokes certainly justifies the small risk of a device embolism.

The Watchman device not only reduces the risk of an ischemic stroke, but also the risk of a hemorrhagic stroke by reducing or eliminating the need to take warfarin or other anticoagulants.

http://www.theheart.org/article/1124905.do

OCTOBER 25, 2010 New story in the Personal Experiences section of A-Fib.com.

Awake during an Electrical Cardioversion Shock

    Though he was supposed to be completely unconscious from general anesthesia, A-Fib patient Kris was somehow awake when he was shocked during an Electrical Cardioversion to restore his heart to normal sinus rhythm. He describes how it felt:
    "The only bad thing was the 'sharp knife pain' that hit my heart which didn't last very long. The humor can be found in me hearing someone say 'ouch' and wanting to know why I hit the bed. The electrical voltage does cause you to jump. But it isn't any worse than having sucked your thumb as a little kid, plugging the same wet thumb into a light fixture, and getting shocked."

OCTOBER 19, 2010 The FDA has approved dabigatran! A-Fib patients now have an alternative to warfarin (Coumadin)! See Dabigatran to Replace Warfarin. http://www.theheart.org/article/1138703.do

SEPTEMBER 29, 2010
    New story in the Personal Experiences section of A-Fib.com: Two Failed Ablations in 2006. Finally success in 2010

SEPTEMBER 20, 2010
    FDA Advisory Panel Unanimously Approves Dabigatran
    An FDA advisory panel unanimously recommended approval of the anticoagulant dabigatran---an oral thrombin inhibitor (brand name Pradaxa by Boehringer Ingelheim). The 18,000 patient RE-LY trial (Randomized Evaluation of Long-Term Anticoagulant Therapy) showed low dose dabigatran was as good as warfarin, while the high dose was better at preventing stroke and systemic embolism. It doesn't require anticoagulant monitoring or major diet changes.
    (Author's Note: Warfarin is one of the most widely used and effective anticoagulants. But it's also one of the most disliked. Dabigatran's recommended approval is a major medical breakthrough and most welcome news for A-Fib patients who will no longer have to cope with measuring INR levels, worrying about diet, vitamin K deficiency, side effects, etc. It's also welcome news for doctors who won't have to wrestle with keeping patients at the right INR levels. They will have an oral anticoagulant that is very effective, has fewer side effects, and can be administered to a broader range of patients.
    Upon FDA approval [almost assured] will dabigatron (and/or ticagrelor) replace warfarin? Probably not right away. A-Fib patients doing well on warfarin and maintaining their INR between 2-3, might be advised not to switch. Dabigatran (and ticagrelor) do not use INR to measure their anticoagulant effectiveness. This can be somewhat disconcerting to A-Fib patients who measure their INR and know they are being protected from an A-Fib stroke.
    Doctors would risk malpractice suites if they would switch someone from warfarin and that person had a stroke. [A small number of people on warfarin at the proper INR levels do still have strokes. Warfarin reduces but doesn't totally eliminate the threat of an A-Fib stroke.] These new anticoagulants are very effective, but they are not full proof and most likely will not totally eliminate the threat of an A-Fib stroke.)
http://www.theheart.org/article/1123797.do

SEPTEMBER 18, 2010
    FDA Advisory Panel Approves the Anticoagulant Ticagrelor
    An FDA advisory panel recommended the approval of the antiplatelet drug ticagrelor (brand name Brilinta by AstraZeneca). (Clinical trial PLATO---Platelet Inhibition and Patient Outcomes.) Ticagrelor reduced the rate of MI (heart attack), stroke, and cardiovascular death compared with Plavix (clopidogrel).
    http://www.theheart.org/article/1106859.do

September 15, 2010
    Calcium Supplements Danger
    Calcium supplements (at least 500mg/day) without vitamin D were associated with a 30% increase in heart attacks. (Vitamin D is necessary for calcium absorption.)
    This increase in heart attacks may occur because "calcium supplements speed vascular calcification and...increase cardiovascular events and MI (Myocardial Infarction---heart attacks) in women." Dr. Ian Reid in an article in Bottom Line Health adds, "Calcium from supplements, including antacids such as Tums and Rolaids, elevates blood calcium quickly, which may contribute to artery disease." Whereas "calcium in foods is absorbed slowly."²¹⁷
    However, an article in Bottom Line Health points out that the researchers in this study did not analyze what happens when calcium is taken with Vitamin D. The study excluded people who were taking vitamin D. But according to Dr. John Schindler "Vitamin D is protective from a cardiovascular standpoint."²¹⁵
    The Bottom Line Health article somewhat disputes the calcium danger findings. "The majority of existing studies have shown no link between calcium supplements and heart attack risk," and suggests that eating calcium-rich foods is a safe way for most people to boost their intake of calcium.²¹⁶
    (Author's Note: Calcium supplements may also trigger or make the heart more susceptible to A-Fib attacks. See WARNING: DANGER OF TOO MUCH CALCIUM !.)
    http://theheart.org/article/1108009.do

SEPTEMBER 13, 2010 New question answered in the FAQs section:
    "During the ablation procedure A-Fib doctors actually burn within the heart with RF energy. How does this burning and scarring affect how the heart functions? Should athletes, for example, be concerned that their heart won't function as well after an ablation?"
    Particularly during ablations for persistent (Chronic) A-Fib, long procedures and extensive ablation are often required. These result in significant scarring and damage to heart tissue. But a study from the French Bordeaux group found "recovery of atrial contractile function" (the heart goes back to beating and contracting normally) in 98% of patients in sinus rhythm after six months of follow-up.²¹⁴
    In general, the less ablation and heart scarring, the better. But it's encouraging that from this preliminary study, even after extensive ablations, the heart usually returns to normal.

SEPTEMBER 6, 2010
    New question answered in the FAQs section:
63. What causes Paroxysmal (occasional) A-Fib to turn into Persistent (Chronic) A-Fib?
    Researchers are still working to find the answer(s) to this question. The main trigger seems to be increased pressures in the left atrium that causes the muscle fibers around the pulmonary vein openings to start beating on their own. Uncontrolled blood pressure, untreated sleep apnea, or a worsening cardiomyopathy seem to be key factors that make people progress from Paroxysmal to Persistent A-Fib. (Thanks to Dr. Sidney Peykar for these observations.)
    Even after a successful ablation for Persistent A-Fib, "the long term success rates depend mostly on treatment of hypertension and obstructive sleep apnea."

SEPTEMBER 3, 2010
    Anticoagulants (Coumadin) can be stopped 3-6 months after a successful Pulmonary Vein Ablation (Isolation)
    In a study of 3,355 patients who had a successful PVI, some stopped taking anticoagulants after 3-6 months, while the second group kept on taking anticoagulants. Only two of the 3-6 month group and three of the second group had an ischemic stroke. Whereas 13 (2%) of the second group had a major hemorrhagic stroke.
    (Author's Note: From this study there doesn't seem to be a need or benefit for anticoagulation for more than 3-6 months after a successful PVI.) "The risk/benefit ratio favored the suspension of oral anticoagulants after successful A-Fib ablation even in cases of patients at moderate-high risk of TE (thromboembolic events---strokes)."
    Themistoclakis S. et al. "The risk of thromboembolism and need for oral anticoagulation after successful atrial fibrillation ablation." J Am Coll Cardiol. 2010 Feb 23;55(8):735-43.
    http://www.ncbi.nlm.nih.gov/pubmed/20170810?dopt=Abstract

SEPTEMBER 2, 2010
    A-Fib patients at risk of dementia
    In a study of 37,025 aging patients, 27% developed A-Fib, and 4.1% of these developed dementia during the five year follow-up. A-Fib was significantly associated with all types of dementia, particularly in the younger group (under 70 years of age). And dementia combined with A-Fib put patients at a high risk of death.
    (Author's Note: Treatment strategies to keep people in A-Fib while controlling the heart rate (rate control meds) may lead to dementia and early death.)

Bunch TJ, et al. "Atrial fibrillation is independently associated with senile, vascular, and Alzheimer's dementia." Heart Rhythm. 2010 Apr;7(4):433-7. Epub 2009 Dec 11.
http://www.ncbi.nlm.nih.gov/pubmed/20122875?dopt=Abstract

AUGUST 31, 2010
    Magnesium Importance for A-Fib

In a letter to the editor of BMJ (British Medical Journal) Drs. Dietch, Wilson and Thomas point out that magnesium is important in regulating the electrical activity of the heart and can help cases of acute A-Fib. "Treatment with magnesium may correct rhythm disturbances in patients with both low and normal magnesium concentrations." Magnesium is "superior to amiodarone in treating atrial tachycardias in critically ill patients."

"It is our impression that magnesium is underused; should we not use it more widely?"

(Author's Note: Magnesium is a naturally occurring element that we should be getting from the food we eat. However, almost everyone today is magnesium deficient, due to the lack of magnesium and other trace elements in today's over-farmed soil (some magnesium can be obtained from fish). Because it is a naturally occurring element, magnesium is considered safe to take in normal doses. "Magnesium is a relatively safe drug." It is certainly safer than amiodarone or other antiarrhythmic meds.

In addition to cases of acute A-Fib, all A-Fib patients may want to discuss with their doctor whether magnesium supplements might help their A-Fib.)

BMJ Letters "Magnesium is underused in acute atrial fibrillation." 1996;312:1101 (27 April)

AUGUST 29, 2010
    Effects of a successful catheter ablation
    In an analysis of 17 different studies enrolling 869 patients, a successful catheter ablation significantly decreased (improved) left atrial diameter and volume, but had no significant difference in ejection fraction and actual emptying fraction.
    (Author's Note: It's certainly reason for hope for A-Fib patients, that a successful A-Fib ablation will not only stop but reverse some of the remodeling effects of A-Fib. But these results seem counter-intuitive. If left atrial diameter and volume are decreased (improved), one would expect ejection fraction to improve as well.)

Jeevanantham, V et al. "Meta-analysis of the effect of radiofrequency catheter ablation on left atrial size, volumes and function in patients with atrial fibrillation." Am J Cardiol. 2010 May 1;105(9):1317-26.
http://www.ncbi.nlm.nih.gov/pubmed/20403486?dopt+Abstract

AUGUST 29, 2010
    Carotid Sinus Stimulus (Massage) by manual pressure for A-Flutter/A-Fib
    Carotid Sinus Stimulation or Massage is a technique used by doctors to partially block or slow down the flow of blood through the carotid sinus. It is used to tell the difference between different types of arrhythmias, and "rarely, may also terminate the arrhythmias and reestablish sinus rhythm." It is used in patients "in whom a rapid decrease in heart rate is desirable."
    Dr. Nayab Ali describes why carotid sinus massage may work. "Vagal Stimulation, by altering the atrial refractory period, may break the circus movement, atrial reentry, and atrial response to ectopic focus, thus allowing the sinus node to take over control."²¹²
Nayab Ali, "Conversion of Atrial Flutter to sinus rhythm by carotid sinus pressure." Journal of the National Medical Association, Vol. 74, NO. 8, 1982.

    WARNING: Carotid Sinus Stimulus or Massage should be done only by doctors and not by individual patients on themselves.

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

AUGUST 28, 2010
    CryoBalloon & RF Ablation---the future of A-Fib treatment
    CryoBalloon ablation is safe and effective in Pulmonary Vein Isolation, but is limited in treating persistent A-Fib (because it only isolates the pulmonary veins and not other parts of the heart). Doctors at Mass General used a combined CryoBalloon and RF ablation to treat patients with persistent A-Fib. (The FDA has not yet approved the CryoBalloon catheter for general use.)
    First a PVI was done using the CryoBalloon catheter. It took approximately 10 minutes to isolate each vein (a considerable savings in time compared to a typical RF ablation). 6% of patients required additional RF ablations to completely isolate the pulmonary veins.
    Then an RF catheter was used to ablate complex fractionated electrograms (CFAEs). Finally linear ablations were performed with the RF catheter to terminate the persistent A-Fib.
    After a single procedure 86.4% of patients were A-Fib free without antiarrhythmic drugs (a high success rate for persistent A-Fib after only one procedure).
    (Author's Note: The above study only dealt with cases of persistent A-Fib. But this combination of CryoBalloon {or possibly Laser Balloon] and RF will probably become the standard treatment for all cases of A-Fib.
    Because the CryoBalloon is safe, effective, and fast, it will probably become the normal method of isolating the pulmonary vein openings. If A-Fib remains after the CryoBalloon ablation, then RF can be used to ablate other areas of the heart that produce A-Fib signals. This combination of CryoBalloon and RF ablation is a major medical breakthrough in the treatment of A-Fib.)
Heart Rhythm. 2010 Apr;7(4):452-8. Epub 2009 Dec 24
http://www.ncbi.nlm.nih.gov/pubmed/20188229?dopt=Abstract

     AUGUST 27, 2010
    Bypass Surgery and A-Fib
    It is estimated that one out of three bypass surgery patients will suffer at least one episode of A-Fib after surgery. 40% of these will have more than one A-Fib attack.
     Beta-blockers and ACE inhibitors, as well as potassium and non-steroidal anti-inflammatory drugs (NSAIDS) appear to reduce the risk of developing A-Fib after bypass surgery.
    The risk factors most associated with developing A-Fib after bypass surgery are:
        - Advancing age,
        - Past history of A-Fib,
        - Chronic obstructive pulmonary disease,
        - The discontinuation of beta-blockers and ACE inhibitors after bypass surgery.
(It was assumed that patients were too sick after surgery to continue to take beta-blockers or ACE inhibitors. But according to this study, "the discontinuation of beta-blockers and ACE inhibitors would be unwise, and their use appears to be protective.")

    (Author's Note: It wasn't clear whether this study included antiarrhythmic drugs. The author questions whether administering antiarrhythmic meds after bypass surgery [similar to what is often done after an A-Fib ablation] might prevent the development of A-Fib after bypass surgery.)
http://www.scienceblog.com/community/older/2004/3/20042692.shtml

AUGUST 26, 2010
    Fibrosis in A-Fib: Chicken or the Egg?
    In a study indirectly related to A-Fib, it was found that fibrosis leads to or is the cause of the development of cardiomyopathy, rather than being caused by or a result of the disease. (People with cardiomyopathy often have A-Fib as well.) According to Dr. Carolyn Y Ho of Brigham and Women's Hospital in Boston, MA, "...the development of fibrosis might play a role in actually driving the development of the disease, rather than being a reaction to the development of overt disease."
http://www.theheart.org/article/1109291.do
    (Author's Note: Since fibrosis also occurs in A-Fib, strategies to prevent fibrosis or to identify factors such as genetics, diet, life style, chemical/biological markers, etc. which influence the development of fibrosis may help prevent the future development of A-Fib. "...targeting fibrosis...may help to forestall the development of clinical disease."²⁰⁹)

AUGUST 18, 2010
    Dr. John Sirak of the Ohio State University has developed a type of Mini-Maze surgery for A-Fib---the "Five-Box Thorascopic Maze Surgery" or Total Thorascopic Maze (TTM) which, according to his web site, 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/

AUGUST 13, 2010 New question answered in the FAQs section:
    "I am having a Pulmonary Vein Ablation next week for my A-Fib. Because i love to exercise, I am very curious as to what and how much physical activity I can participate in after the procedure. Everything i read says 'You can resume normal activity in a few days.' But i know that what is "normal" is not normal for me. Is there a range of BPM (beats per minute) to keep my heart within? Light walking? Exercising/light weights in the gym? Is there a common road to recovery for those of us who are very physically active?" (Thanks to Monique Van Zeebroeck for this question.)
    Caution would say to start off slow, then work your way up. You could get a Polar (or other) heart rate monitor to keep track of your heart rate. Your heart is considered healed from the scarring of the ablation after three months (possibly sooner).
    Often you feel so good being in sinus rhythm after an ablation, that you can't wait to exercise, to do something physical. But even though you feel great, it's better to be prudent and rein yourself in for a short while.
    (A special thanks to Ed Webb, a very active exerciser, who shares his following experiences and insights.)

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

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

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

August 9, 2010
    In a study of 50 patients who underwent Mini-Maze surgery, 40% had recurrences of arrhythmias during the healing process, in a follow-up study of 12 months. PV reconnection accounted for most recurrences. Most patients' A-Fib was terminated by catheter ablation, often combined with antiarrhythmic and rate control meds.²⁰⁸ (Catheter Ablation procedures also have significant recurrence rates.)
    (Author's Note: This article may be very important to A-Fib doctors and researchers, because it identifies specific areas of the heart where re-growth/recurrence is likely to occur. "The relative thickness of human myocardium, particularly in areas with endocardial ridges, as well as the presence of blood flow, may explain the discrepant results between patient outcomes..."
    The author questions whether other energy sources like Cryo or Laser might help both surgery and catheter ablation overcome this problem of re-growth/re-connection after surgery and ablation for A-Fib.
    Catheter ablation does follow the contours and ridges of the heart. Can the catheter be programmed to produce deeper burns in areas of greater heart thickness like endocardial ridges? This might be a solution to a very troublesome problem for both A-Fib doctors and patients.)

august 8, 2010 In a major revision of A-Fib.com, the "Natural" Remedies section has been revised and placed first under Treatments.

"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 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.²⁰⁰You may need to work with your doctor to determine the benefit of 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.

    "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
    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.
    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?
    Two 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 iherb.com.
    * Angstrom Magnesium: such as "New Beginnings Liquid Magnesium - Ionic Liquid Concentrate," available from evitalhealth.com

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.)
    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
    Another alternative treatment is Epsom Salts Baths. See Personal Experiences section Epsom Salts Cure.

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 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

    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).
    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.¹⁹²Too 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)¹⁹⁷HAWTHORNE BERRY   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 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.¹³⁵Taurine 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 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 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).¹³³Dr. 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/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 The two products below have a desired high ratio of DHA compared to EPA.
    * 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) 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 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.

MAY 22, 2010 vernakalant successful in stopping A-Fib
    For A-Fib patients with underlying heart disease, the intravenous med Vernakalant converted 51.7% of A-Fib patients to sinus rhythm after only around 11 minutes. It was shown to be safe, well tolerated, and associated with greater improvements in quality of life (the AVRO trial). An FDA advisory panel voted in favor of vernakalant, but the FDA still has not approved it in the US.¹⁸³ http://www.theheart.org/article/1079027.do
    (Vernakalant is a medical breakthrough for A-Fib patients with structural heart disease who cannot use other antiarrhythmic drugs, if the FDA approves it.)

MAY 21, 2010 Ablation of A-Fib reduces risk of Alzheimer's and dementia
    In a large population study (37,908) at the Intermountain Medical Center in Utah, some patients with A-Fib received catheter ablation treatment, while others received drug therapy. After three years of follow-up, the rate of Alzheimer's disease and all forms of dementia was significantly lower among patients who underwent catheter ablation. According to Dr. John Day, "In fact, the rates we saw were similar to those that you'd see in patients who never had A-Fib to begin with." Catheter ablation also reduced the risk of mortality and stroke at three years.^182*
    (Catheter ablation may reduce Alzheimer's and dementia:
    1. By improving and/or normalizing blood flow to the brain.
    2. By reducing inflammation. There may also be an inflammatory connection, "with both A-Fib and Alzheimer's disease associated with high levels of C-reactive protein."
    3. By reducing and eliminating TIAs and subclinical strokes caused by A-Fib. These mini-strokes produce amyloid plaque found in Alzheimer's disease patients.)
    Catheter ablation reduces the risk of mortality and stroke, and reduces the risk of Alzheimer's and dementia. Then why leave A-Fib patients on medications? As Dr. Day suggested, "...if you have A-Fib and medication isn't working, maybe we should move toward a potentially curative procedure earlier, rather than spinning our wheels for years with medication."¹⁸¹ http://www.theheart.org/article/1079365.do
     *The title of reference ¹⁸² is confusing. I have written the author for a clarification.

MAY 17, 2010
    High dose steroids may cause A-Fib.
    In a case-control study in the Netherlands involving 7,983 men and women, high-dose corticosteroid use significantly increased the risk of developing A-Fib. (Corticosteroids include meds such as prednisone, cortisone, hydrocortizone, budesonide, betamethasone, dexamethasone, Advair. High-dose refers to a daily dose greater than 7.5 mg of prednisone equivalents.)
    But it's dangerous to suddenly stop taking steroids. Sudden withdrawal can lead to serious side effects and, in some cases, be life threatening.¹⁸⁰ http://www.theheart.org/article/696423.do

May 15, 2010
    Dr. Andrea Natale has been named the Director of Interventional Electrophysiology at Scripps Clinic in La Jolla, CA (April 5, 2010). Here is his address info:
Scripps Clinic
10666 N. Torrey Pines Rd SW 206
La Jolla, CA 92037
(858) 554-5049
    Dr. Andrea Natale, Director of Interventional Electrophysiology
    Dr. Douglas N. Gibson (858) 554-8730
Dr. Natale is also available to help A-Fib patients in other areas of the US: see
    ---Austin, Texas Dr. Natale is the Executive Director of the Texas Cardiac Arrhythmia Institute
    ---Akron, Ohio Akron General Medical Center
    ---Cleveland, Ohio MetroHealth Medical Center
    ---San Francisco, CA Northern California Heart Center

April 21, 2010
    New question answered in the FAQs section: "I just had an Electrical Cardioversion. My doctor wants me to stay on Coumadin for at least one month. Why is that required?
    They mentioned something about a "stunned atrium." What is that?" (Thanks to David Mobley for this question.)
    A "stunned atrium" is medically defined as a "state of temporary mechanical atrial dysfunction with preserved bioelectrical function"¹⁷⁸---in non-medical terms your heart doesn't contract properly even though is it getting the right electrical and chemical signals to contract. This can happen after an Electrical Cardioversion and is why the left atrium and, in particular, the Left Atrial Appendage tend to develop clots after an Electrical Cardioversion.
    The Left Atrium, and especially the Left Atrial Appendage, is "stunned" after the electrical shock and may not immediately contract and pump out properly. Clots can develop and be released when the LAA starts to contract again.¹⁷⁹ That's why you need to be on a blood thinner like Coumadin for a month after your Electrical Cardioversion.

APRIL 15, 2010
    Women with A-Fib had a higher stroke risk, more stroke-related disability, and were less often prescribed blood thinners, according to researchers analyzing past A-Fib studies comparing how A-Fib affects men and women. Doctors may be more reluctant to prescribe warfarin (Coumadin) to women, because some evidence shows that women have a significantly higher risk of bleeding from blood-thinning medication.¹⁷⁷
    (If you are a women with A-Fib, make sure you consult with your doctor about the risk-benefit of taking blood thinners. An A-Fib stroke is often a fate worse than death. See Anticoagulants.)

February 14, 2010
    New question answered in the FAQs section: "Where can I get more information on what was done to my heart during my Pulmonary Vein Ablation?"
    Ask your doctor or his office for your O.R. (Operating Room) report. This is a technical, detailed, step-by-step account of what the doctors found in your heart and what was done. Because it is technical and hard to understand, it isn't normally given to patients unless they ask for it. (If you need help understanding it, email or send me a copy [Feedback]. Together we can probably figure it out.)

February 13, 2010
    New question answered in the FAQs section:
    "I just had a Pulmonary Vein Ablation. But my A-Fib feels worse and is more frequent than before the ablation, though I do seem to be improving each week. My doctor said I shouldn't worry, that this is normal. But I feel terrible. Is my ablation a failure?"
    You won't know if your ablation is a success for about three months. It takes that long for your heart to heal.
    There is a period of time (which varies from patient to patient) when the A-Fib may seem to get worse. This happens in some people because of the inflammation and trauma to the heart and body tissues caused by the catheter ablation burns and the poking around in your heart during the procedure. These can seem to exacerbate your A-Fib. (An ablation procedure doesn't create new A-Fib producing areas in your heart, though it may stir up existing A-Fib areas temporarily.)
    Another reason you may still have A-Fib is because of gaps in the ablation lines. In the most common A-Fib ablation procedures used today, doctors try to create ablation lines around your pulmonary vein openings to isolate them from the rest of your heart. (A-Fib producing areas are usually found inside your pulmonary vein openings.) But it's difficult making continuous, perfect ablation lines. Sometimes there are gaps in those lines which let A-Fib signals through. But as your heart heals, these gaps usually fill in with scar tissue.

    Remember, also, that it isn't the end of the world if your ablation isn't a total success. Some 15-20% of ablations are not successful. These patients have to go back for a second ablation (including myself). This touch-up ablation is usually much easier than the first. Often all the doctor has to do is ablate any gaps that haven't filled in or ablate where there has been re-growth/re-connection. See Second Ablations.

    If you want more specific information about your ablation procedure, ask your doctor or his office for your O.R. (Operating Room) report. (It's very technical. You can email or send me a copy if you want help reading it [Feedback]. See the Operating Room Report question.)
(Thanks to A-Fib Support Volunteer Jerry for helping write this answer.)

February 10, 2010
    New question answered in the FAQs section: "I know I'm at risk of an A-Fib stroke, but I hate taking Coumadin. Aren't there any natural remedies or supplements I could take?"
    There are "natural" remedies that thin the blood. But there isn't much research on their effectiveness in preventing an A-Fib stroke.
    Realize also that your doctor isn't likely to tell you to stop taking prescription blood thinners like Coumadin (warfarin) and Plavix. That would be legal suicide. Even people on Coumadin with the proper INR levels get strokes. Coumadin reduces the annual risk of an A-Fib stroke by two-thirds,⁴⁵ but it doesn't eliminate it entirely. However, if your doctor took you off of Coumadin and you had a stroke, he/she could be sued.
    The same is true for this web site which is not recommending or suggesting you quit taking prescription blood thinners.
    Here are two "natural" remedies that are thought to thin the blood. Again, how effective these "natural" blood thinning regimens are to prevent A-Fib stroke has not been scientifically established.

Another similar regimen is the following:

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

15th BOSTON A-FIB SYMPOSIUM, January 14-16, 2010 "Atrial Fibrillation: Mechanisms and New Directions in Therapy"

    The annual international Boston A-Fib Symposium is one of the most important conferences on A-Fib in the world. It brings together researchers and doctors who share the latest information. However, if you haven't read and understood most of A-Fib.com, it may be difficult reading.

OVERVIEW-HIGHLIGHTS

    The overall mood of the 15th annual Boston A-Fib Symposium seemed to be a sense or feeling of certainty in making progress and moving forward.
    One might describe this Symposium's signature or most prominent topic of interest as "New Achievements in A-Fib Imaging/Mapping."

4D & 5D IMAGING/MAPPING IN A-FIB
    In a thought provoking and somewhat controversial presentation, Dr. Douglas Packer described new developments in A-Fib Imaging/Mapping as "4D and 5D Imaging."
    Over the last few years, A-Fib doctors and medical companies have developed very sophisticated Imaging/Mapping systems for doing A-Fib ablations. For example, in the Satellite Case Transmission presented by Massachusetts General, Dr. Moussa Mansour watched on a monitor a 3D rotating, detailed color cartoon image of the patient's heart. He then pushed a button to open up the end of the heart and look inside.
    Rotational Angiography produces even more astounding images. Instead of cartoon recreations, it shows the patient's actual heart in a 3D, real time rotation. One can see the heart in every detail and can watch where the ablation catheter is in the heart. (Seeing this for the first time takes one's breath away.)
    (The author is negotiating with different Imaging/Mapping companies to make their images of the heart available on A-Fib.com.)
    Time is the 4th A-Fib Dimension, according to Dr. Packer. An example is the CardioFocus Endoscopic laser balloon Ablation System. The doctor operating the CardioFocus catheter can directly see in color 3D real time where the CardioFocus laser balloon is positioned in the heart. The operator also sees tissue change imaging (A-Fib 4D), how the heart tissue is affected over time as the Near Red Laser Light ablates in overlapping arcs around the Pulmonary Vein opening. (This system is not yet approved by the FDA for use in the US.)
    The 5th A-Fib dimension would include other parameters such as integrated temperature sensing imaging probes (and contact force imaging---how much pressure an ablation catheter applies when ablating heart tissue).

ATHLETES AND A-FIB
    Athletes and endurance training was the subject of two sessions and a great deal of discussion. Dr. Stanley Nattel presented studies indicating that high level physical training doubled the risk of developing A-Fib. In Dr. Nattel's animal lab experiments, high level exercise training (30+ miles/week) developed A-Fib by two mechanisms:
    1. increasing Vagal tone,
    2. producing structural remodeling of the heart---atrial overload leads to atrial enlargement, increases atrial fibrosis and ventricular hypertrophy.
    Dr. Riccardo Cappato described how A-Fib hurts athletes' performance and their ability to exercise. It also makes them ineligible for competitions because they fail pre-qualifying tests (other professions and avocations such as pilots have this same problem).
    Because athletes often can not tolerate antiarrhythmic drugs and/or refuse to take them, Dr. Cappato and other doctors in a panel discussion say they recommend Pulmonary Vein Ablation as first line treatment for athletes. A successful PV ablation restores athletes to full competition intensity and makes them re-eligible to compete.
    Current guidelines state "catheter ablation of A-Fib in general should not be considered as first line therapy." At least one antiarrhythmic med should be tried first. But the guidelines also state, "in rare clinical situations, it may be appropriate to perform catheter ablation of AF as first line therapy." Dr. Eric Prystowsky, who was instrumental in writing the current A-Fib guidelines, stated that he uses PV Ablation as first line therapy for athletes because of the above reasons.

ABLATION NOT A PERMANENT "CURE" FOR A-FIB
    When counseling patients with A-Fib, a successful A-Fib ablation is considered the only current hope of a permanent "cure" for A-Fib (as compared to, for example, Rhythm or Rate control drugs which tend to lose their effectiveness over time). But a study by Dr. Francis Marchlinski cast doubt on this hypothesis.
    He persuaded patients who had experienced successful PV ablations and who were A-Fib symptom free, to be re-examined in the EP lab. He found that some had Regrowth/Reconnection in their ablated vein openings even though they were A-Fib symptom free. He also examined patients who had Regrowth/Reconnection and reoccurrence of A-Fib after a successful PV ablation.
    He estimated that there is a 5-6% chance of Regrowth/Reconnection each year, out to five years. He doesn't have data for beyond five years.
    (The author has been A-Fib symptom free for 12 years. Doctors he spoke to didn't think there was much chance of A-Fib reoccurrence after 12 years.
     However, the author will eliminate the work "cure" from all A-Fib.com postings and instead use the term "A-Fib symptom free.")

CONTACT FORCE SENSING
    A Mini-Symposium was devoted to the subject of Contact Force Sensing.
    When performing an ablation, doctors monitor power, duration, and temperature; but not how hard the ablation catheter presses on heart tissue. Insufficient ablation catheter contact can produce lesions that don't work or that do not penetrate heart tissue, while too much contact or pressure can cause perforation or damage to adjacent structures like the esophagus.
    Dr. Karl-Heinz Kuck described a study using the TactiCath contact force sensing system which found a high variability of force applied both between different operators (which one would expect), and during an ablation by one operator. 12% of ablation burns had a low force contact of under five grams. (Perhaps this is one of the causes of re-occurrence of A-Fib after ablation.) 82% of patients had a force of over 100 grams applied at least once during their ablation. This could potentially cause steam pop, puncture, and clotting. Dr. Hiroshi Nakagawa explained how Contact Force Sensing catheters would eliminate the above problems.
    Dr. Dipen Shah presented studies which showed that Contact Force Sensing:
        1. Improves lesion effectiveness
        2. Reduces ineffective applications (by indicating insufficient contact force)
        3. Reduces collateral damage
        4. Improves safety
        5. Predicts sites of conduction recovery

STROKE PREVENTION
    A Mini Symposium was held on Stroke Prevention in A-Fib.
    Dr. David Singer described why A-Fib is a major risk factor for stroke. Because in A-FIb the left atrium doesn't contract to push blood into the ventricle, clots can easily form especially in the Left Atrial Appendage.
    Warfarin (Coumadin) reduces the risk of stroke by 68% and is safe at the proper levels. Warfarin's risk of producing an hemorrhagic stroke is only 0.3%/year compared to a normal risk of 0.1%/year. But warfarin is underused. 40% of people who should be on warfarin don't take it, perhaps because of its side effects, bleeding risk, and the difficulty in maintaining proper INR levels.
    Aspirin is much less effective, only reducing the risk of stroke by approximately 21%. Clopidogrel, when taken with aspirin, reduces the risk of stroke by approximately 28%. But it significantly increases the risk of major hemorrhage, mostly gastrointestinal.
    The good news, both for patients and doctors, is stroke rates in A-Fib are declining.

DABIGATRON TO REPLACE WARFARIN?
The RE-LY study found that dabigatron reduces the risk of stroke by 30% while also reducing the risk of intracranial bleeding by 30% (dabigatron dose 150 mg). It also reduces vascular death. Unlike warfarin which needs four days loading to be effective, dabigatron works right away. It doesn't have to be monitored for INR levels. (Both doctors and patients are impatiently waiting for FDA approval for dabigatron, which hopefully will come soon.)

THE WATCHMAN DEVICE TO PREVENT STROKE
    The Watchman Device works by closing off the Left Atrial Appendage where 90% of clots/strokes come from. (See The Watchman Device.)
    Dr. Zoltan Turi showed a slide of a man who had a Watchman Device installed, but died nine months later from other causes. His family graciously allowed doctors to do an autopsy to examine how the Watchman device had worked. The Watchman Device was covered over by smooth heart muscle tissue which looked like any other part of the heart. (The Editor is negotiating to get a copy of this slide for A-Fib.com.)
    Data from the Watchman Device study showed that it is safe, effective and easily installed (one doctor said he installed them in 20 minutes). A surgeon speaking at the Symposium said he had to remove Watchman Devices (implying that this is a major problem with the Watchman Device). Acknowledging there was a short learning curve when first installing the Watchman Device, Dr. Turi said that to date only four have had to be removed.
    An FDA preliminary panel has approved the Watchman Device. But the vote was close---7-5. All agreed that the Watchman Device worked, but some wanted to see more than 800 cases. Clinical trials of the Watchman Device have been extended.

FDA AT THE BOSTON A-FIB SYMPOSIUM
Dr. Randall Brockman and Dr. Jun Dong from the FDA both expressed the FDA's willingness to help and encourage the development of effective therapies for A-Fib. Dr. Brockman pointed out that A-Fib is a major public health issue (some have called it an epidemic). He also expressed the FDA's interest in developing an A-Fib Registry (SAFARI). (He was asked why new devices or drugs seem to be always started in Europe.)
Dr. Dong explained the FDA's Investigational Device Exemption (IDE) and how it could be used by both industry and physicians. He welcomed physician-initiated trials and gave the audience his email address and office phone number.

MEASURING QUALITY OF LIFE IN A-FIB
    Having A-Fib can be devastating. A-Fib can affect General and Mental Health, as well as Physical and Social Function.
    Some A-Fib symptoms can be described and objectively quantified by degree and severity: Palpitations, Dyspnea (difficulty breathing), Chest Pressure and Pain, Dizziness, Presyncope, Syncope (fainting), Exercise Intolerance and Fatigue. Other symptoms are more subjective: such as Anxiety and Depression.
    "Quality of Life" is a subjective phenomenon based on each person's perception, experience, beliefs, and expectations. What may be intolerable for one person may not be all that bad for another. Dr. Jeremy Ruskin is proposing an A-Fib Symptom Classification System that also includes Quality of Life. Such a system or universally accepted shorthand would facilitate communication between doctors and patients, and between health care providers.
    CLASS    SYMPTOM SEVERITY
    I.         Asymptomatic
    II.        Mild---having a mild affect on a patient's qualify of life, mild awareness
                of symptoms in Persistent/Permanent A-Fib, rare episodes (less than a
                few a year) in Paroxysmal A-Fib
    III.        Moderate---having a moderate affect on quality of life, moderate
                awareness of symptoms on most days in Persistent/Permanent A-Fib,
                more common episodes (more than every few months) and/or more
                severe symptoms in Paroxysmal A-Fib.
    IV.        Severe---having a severe effect on quality of life, very unpleasant
                symptoms in Persistent/Permanent A-Fib, frequent and highly
                symptomatic episodes in Paroxysmal A-Fib
                Syncope (fainting)
                Congestive Heart Failure because of A-Fib

DR. JEREMY RUSKIN HONORED
Dr. Jeremy Ruskin from Massachusetts General Hospital was honored for his 15 years of organizing the Boston A-Fib Symposium. He was given a Chelsea clock from Boston and was enthusiastically applauded for his years of service to the A-Fib community.

JANUARY 2, 2010
    New question added to the FAQs section:
    "I know I need a Pulmonary Vein Ablation (Isolation) procedure to stop my A-Fib. A-Fib destroys my life. I can't work or exercise, and live in fear of the next attack. Antiarrhythmic meds cause me bad side effects. But I'm worried about being exposed to radiation during the ablation. How dangerous is the fluoroscopy radiation during an ablation?" (Thanks to Stephanie Fagan for this question.)
    Exposure to radioactivity during an ablation used to be a legitimate concern. (Doctors and nurses wore lead aprons during an ablation.) Back in 2003, a typical A-Fib ablation resulted in around 50 minutes of fluoroscopy time.¹⁷²One hour of fluoroscopy imaging is associated with a lifetime three-in-ten thousand chance (0.03%) of developing a fatal malignancy, and a risk of passing on a genetic defect of 20 per 1 million births.¹⁷⁵ These risks were considered relatively small compared to the risks of being in A-Fib, antiarrhythmic drug therapy, and surgery.¹⁷⁴Doctors follow directives which limit the amount of radiation you can be exposed to during an ablation. If you get close to exceeding these limits, they will stop the ablation (though this rarely happens). But many centers today use much less or no fluoroscopy at all. Instead many use 3D non-fluoroscopy (no radiation) imaging techniques such as Intracardiac Echocardiography (ICE), and Magnetic Resonant Imaging (MRI). You need to check with your A-Fib center as to how much radiation their typical A-Fib ablation patient is exposed to. The radiation dose for a typical A-Fib ablation is estimated to be 18.4 mSv.¹⁷⁵However, the radiation amount at your A-Fib center will vary depending on what type of imaging equipment they use.
    Once you learn what amount of ablation radiation you might be exposed to at your A-Fib center, then you can compare it to the following to determine if you should be concerned:
    • Average Background Radiation/year                    2.4 mSv
    • Chest X-Ray Radiation                                        0.02-0.2 mSv
    • Heart CT Scan Radiation (100-600 Chest X-rays)    12 mSv
    • Typical A-Fib Ablation                                        18.4 mSv
But bear in mind that, even a one hour-long exposure to fluoroscopy, is a relatively small risk compared to the risks of being in A-Fib, antiarrhythmic meds, and surgery.
    (The author did a very unscientific survey of the A-Fib medical centers in his area. The average seemed to be 10-20 minutes of fluoroscopy time [for those who used fluoroscopy] for an A-Fib ablation, but more complicated cases could expose patients to 60(+) minutes of fluoroscopy time.)

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

added December 31, 2009 to the FAQs question about Cryo
    The FDA hasn't yet approved the Cryo Cath balloon catheter. We don't know when or if the FDA will approve it. It is currently not available in the US even in clinical trials which have terminated (it is available in Europe). it may be available in special circumstances of "compassionate use." But this "compassionate use" exception is often difficult to obtain.
    You can get an ablation using just a Cryo catheter, but it currently takes too long to do a good Pulmonary Vein Isolation ablation. And, probably because it takes so long, it doesn't seem to work as well as an RF ablation.
    Doctors have been doing RF ablations for years. They work. The Cryo Balloon and RF catheter ablations are pretty much equally effective. The Cryo Balloon is safer, but not that much safer than RF which is a low risk procedure.
    If we had a choice between the Cryo Balloon and RF, we'd probably choose the Cryo Balloon. But right now we don't have that choice. An RF ablation remains a good option with a high success rate and low complication rate. (Thanks to Jean Kirkland for suggesting this update.)

december 24, 2009
    The latest worldwide survey of A-Fib ablations includes data on 20,825 catheter ablation procedures performed on 16,309 patients over a four-year period from 2003 to 2006 (some patients had more than one ablation). This is almost twice the number of patients treated compared to the first survey from 1995 to 2002.
    The success rate worldwide was 70% (A-Fib symptom-free without having to take antiarrhythmic drugs), which was a major improvement over the 52% reported in the first survey. The "overall success rate"---defined as freedom from A-Fib with or without the use of antiarrhythmic drugs---was similar in both surveys, at 80%.
    More patients with persistent and long-lasting A-Fib were treated than in the previous survey. Of the 1,108 patients with long-standing A-Fib, the success rate was 63.1%, while the overall success rate was 72.3%.
    The overall complication rate was 4.5%, down slightly from the previous survey. But Transient Ischemic Attacks were cut in half, and Pulmonary Vein Stenosis was reduced by two thirds. (Pulmonary Vein Ablation is a relatively new procedure. More experience, improved techniques and equipment, and the sharing of knowledge have definitely improved the outlook for A-Fib patients.)
    There were 25 procedure-related deaths and 37 strokes, similar to the previous survey. Atypical Atrial Flutter doubled. Atrioesophageal Fistula, not reported previously, occurred in 0.04% of patients, of whom 71% died. (The author is not sure about these figures. 0.04% of 16,309 is only around 7 patients.) (Atrioesophageal Fistula is less of a problem today. Most centers now take precautions to prevent Atrioesophageaal Fistula.)
http://www.theheart.org/article/1035905.do

Author's Conclusions
    Limitations of the survey
        85 electrophysiology centers in North America, Europe, Asia, and Australia provided data for this survey. But there are currently around 200 centers performing A-Fib ablations in the US alone. The 85 centers providing data may be the most experienced, larger centers. Are the newer, smaller centers achieving similar success and complication rates? We simply don't know. (From the author's limited experience, the newer, smaller practices seem to be achieving similar success and complication rates, at least in the US.)
   Insufficient doctors and medical centers for A-Fib
       Though 16,000+ patients seems like a huge number, it's very small compared to the number of people developing A-Fib. Though there has been a tremendous growth in medical centers and doctors doing A-Fib ablations, they can not possibly handle all the cases of A-Fib which some are calling an epidemic. Nearly three million people in the U.S. have A-Fib. By the year 2050, the number will be 5.6 million.⁷¹ In the US people over 40 have a one in four chance of developing A-Fib.⁸² A-Fib needs to become a national and worldwide health issue.
    Remarkable progress in a short time
        A-Fib patients should be encouraged by the remarkable progress doctors have made in A-Fib catheter ablation within a relatively short period of time. The first Pulmonary Vein Ablation was done a little more than a decade ago. A worldwide improvement from 52% to 70% success rate is a notable achievement and a testament to the hard work of A-Fib doctors everywhere.

december 20, 2009
    New section added to the Overview, Causes sections of A-Fib.com:
    Some research has identified a Familial A-Fib where A-Fib is passed on genetically²⁸ but it is relatively rare. (Author's theory: Some consider all A-Fib genetic in that we are born with A-Fib triggers---usually the Pulmonary Vein Openings in the Left Atrium. They seem to be genetically related to and similar in structure to the AV Node, the natural pacemaker of the heart. They usually beat in sync with the AV Node. But when impaired, they start beating on their own producing A-Fib signals. [Be advised that this is only a theory and not established medical fact.])

december 20, 2009 New question answered in the FAQs section:
"I'm worried about having to take the blood thinner warfarin (brand name Coumadin). If I cut myself, do I risk bleeding to death?"
    In general, no. On a normal dosage of warfarin (Coumadin) you will bleed longer if you cut yourself (not a serious wound). But your blood will still clot. You will also bruise more easily.
    You should stay away from contact sports like hockey, football, rugby, etc. or activities where you could easily injure yourself like mountain climbing, competitive biking, etc. Professional athletes should not be on warfarin (Coumadin).
    But you can do normal daily activities on warfarin. However, in case of an emergency, you may want to get a Medical ID Alert to warn paramedics and doctors that you are taking a blood thinner.

december 19, 2009
    Following a Pulmonary Vein Ablation procedure, patients should be given warfarin for at least 2 months regardless of their stroke risk factors (HRS/EHRA/ECAS AF Ablation Consensus Statement).¹²⁵ But a recent study found that "low-risk patients with a low CHADS2 (0-1) score... can safely be discharged on aspirin alone."¹⁷¹ (Thanks to William Pfeifer for calling our attention to this research.)
    (Author's Note: For safety's sake [and to avoid legal liability problems], your doctor will probably still want you to be on warfarin after an ablation.)

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

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

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

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

NOVEMBER 19, 2009
DABIGATRAN TO REPLACE WARFARIN (COUMADIN)
    The above title is presumptuous, because the FDA hasn't yet approved the oral anticoagulant dabigatran. But the recent RE-LY trial comparing dabigatran etexilate (by Boehringer Ingelheim) to warfarin at 951 centers in 44 countries with 18,113 A-Fib patients produced results that are hard to ignore. Low dose dabigatran was as good as warfarin, while the high dose was better at preventing stroke and systemic embolism.
    To paraphrase the lead investigator Dr. Wallentin, dabigatran does not need frequent blood-test monitoring for INR levels, isn't affected by possible food-drug or drug-drug interactions, can be used in many more patients than warfarin, has few side effects, and is more effective and safer than warfarin.
    (The author predicts that dabigatran will be approved by the FDA and will quickly replace warfarin as a treatment to prevent A-Fib stroke. [It is already approved in the European Union and Canada.]} This is a major medical breakthrough and most welcome news for A-Fib patients who will no longer have to cope with measuring INR levels, worrying about diet, vitamin K deficiency, side effects, etc. It's also welcome news for doctors who won't have to wrestle with keeping patients at the right INR levels. They will have an oral anticoagulant that is very effective, has fewer side effects, and can be administered to a broader range of patients.
http://www.theheart.org/article/1024935.do (Thanks to Ira David Levin for calling our attention to this article.)

NOVEMBER 18, 2009
    New question answered in the FAQs section: "I've had Paroxysmal (occasional) A-Fib for a couple of months, but the A-Fib episodes seem to be getting longer and more frequent. I'm worried about going into permanent (Chronic) A-Fib which I know is harder to cure. How long do i have before I go into permanent A-Fib?"
    Worst case scenario, about one year. In a study of 5,000+ A-Fib patients, 54% of those on rate control meds went into permanent A-Fib in one year.¹⁶⁴
    There are people who've had Paroxysmal A-Fib for years and never progress to permanent A-Fib. But the odds are against you. If you don't aggressively try to stop your A-Fib (as with antiarrhythmic meds or a Pulmonary Vein Ablation. etc.), you can expect your A-Fib to become permanent within one year (54% chance).¹⁶⁴

NOVEMBER 17, 2009
RHYTHM (ANTIARRHYTHMIC) MEDS BETTER THAN RATE CONTROL
     In a study of 5604 patients with A-Fib who were treated with either antiarrhythmic or rate control meds, "81% of patients treated with rhythm control, compared with 33% of patients in the rate-control arm were in sinus rhythm, after one year... 13% progressed to permanent A-Fib in the rhythm-control arm, whereas 54% in the rate-control arm had permanent A-Fib after one year." This finding disagrees with the AFFIRM trial which indicated there was no advantage of rhythm control vs. rate control for the prevention of cardiovascular events.
    Author's Note: Though the study found no significant difference in clinical outcomes, from this patient's perspective it's certainly better to have a normally beating heart than to be in A-Fib---from a clinical as well as from a quality of life aspect. If the study were longer than one year, one would expect to see more heart problems develop in those still in A-Fib. And why isn't progressing to permanent A-Fib not considered a clinical outcome? Anyone who suffers from A-Fib dreads and fears going into permanent A-Fib.
    A disturbing point mentioned in passing in this study is the high percentage of patients (54%) in the rate-control arm who progressed to permanent A-Fib within one year! This should be a wake-up call to all A-Fib patients. If you don't aggressively try to stop your A-Fib (as with antiarrhythmic meds or a Pulmonary Vein Ablation. etc.), you can expect your A-Fib to become permanent within one year (54% chance).
    This RECORD AF Registry data was presented at the American Heart Association 2009 Scientific Sessions by Dr. John Camm. http://www.theheart.org/article/1023939.do (Thanks to Ira David Levin for calling our attention to this article.)

NOVEMBER 15, 2009
    Under "Natural" Remedies, Harold Bosworth writes that Branched Chain Amino Acids (BCAAs) coupled with L-Glutamine got him out of Chronic (continuous) A-Fib after taking it for 2 days. He had been in Chronic A-Fib for 3 years. (MRM 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. 2 teaspoons in the morning and evening.) "Don't know if this will work for everyone, but it sure worked for me."
Email: capthb(at)sbcglobal.net (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.)

OCTOBER 1, 2009
    dr. j. Marcus Wharton of the Medical Un. of South Carolina has a very informative 18 minute audio presentation on A-Fib Ablation http://www.muschealth.com/multimedia/Podcasts/displayPod.aspx?podid=252&autostart=true

September 2, 2009
    A new topic was added to the Overview of the 2009 Boston A-Fib Symposium:
_{Genetics may play a very
significant role in the development of A-Fib

    Dr. Dan
Roden of Vanderbilt University described how genetic research may become very
important to A-Fib patients. He predicted that within five years research may
identify what genes predispose a patient to A-Fib. Then personalized therapy can
be developed based on the patient's genes. "Lone A-Fib" (A-Fib without a known
cause) may actually be caused by genetics.

    The full report of Dr. Roden's presentation is also
available:} The Role of Genetics in the Development of A-Fib.

august 17, 2009
    New question answered in the FAQs section: "I've been on amiodarone for over a year. It works for me and keeps me out of A-Fib. But I'm worried about the toxic side effects. What should I do?"

August 14, 2009
    We are very excited about starting a new way of helping people with A-Fib. Many people who've had A-Fib have generously committed to serve as A-Fib Support Volunteers, to help people cope with and be cured of A-Fib. They've listed their Email addresses and are there for anyone who needs advice, emotional support, and hope in getting through the A-Fib ordeal.

JULY 30, 2009 Dronedarone (brand name Multaq) is now available in pharmacies in the U.S. http://www.reuters.com/article/rbssHealthcareNews/idUSLS59493520090728

JULY 11, 2009 New question answered in the FAQs section:

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

JULY 7, 2009
    New material added to the FAQs question about how one feels after a Pulmonary Vein Ablation:
Right after the PVA(I) you may experience the following:
    1. Your groin will generally have two access site points, one on each side. After a Pulmonary Vein Ablation, some minor bruising is common at each site with minor soreness as if you had banged the area. Bruising may occasionally be seen to extend down the leg. This is normal, as is an occasional small quarter sized bump in the area. (If larger swelling or more significant pain occurs at the area, please contact the electrophysiologist who did the procedure.)
    2. After an Pulmonary Vein Ablation you may have some minor chest pain for the next week or so. The pain will often worsen with a deep breath or when leaning forward. This is pericardial chest pain from the ablation and is generally not of concern. It should resolve within a week, although it might increase for a day or so after the ablation.
    3. Low grade fevers of around 99 degrees are common in the first day or so post-ablation. (If you develop unexplained fevers exceeding 100 degrees anytime within the first 3 weeks post-ablation, you need to contact the electrophysiologist who performed your procedure.)

JULY 2, 2009
    New story in the Personal Experiences section of A-Fib.com: Not Necessary To Go To Top-Name A-Fib Centers To Have Excellent Care and Good Results

JULY 2, 2009
    Dronedarone (brand name Multaq) was approved by the FDA. This is a major medical breakthrough for many A-Fib patients. See Dronedarone. http://www.theheart.org/article/983519.do.
      But there is a caveat. "Dronedarone is not indicated in patients with severe heart failure or those with NYHA (New York Heart Association) class 2 or 3 heart failure with a recent decompensation requiring hospitalization." (Class 2 refers to patients with slight, mild limitation of activity, class 3 refers to patients with marked limitation of activity. "Decompensation" refers to rapid accumulation of fluid in the lungs due to heart problems.) "The ANDROMEDA trial showed that dronedarone increased the risk of mortality twofold among those treated by the drug." This is a major difference from amiodarone which dronedarone is similar to but with less toxic effects. Amiodarone is considered safer for patients with structural heart disease, while dronedarone is not indicated for patients with severe heart failure.

june 20, 2009 Dr. Richard Schilling of the London AF Center is doing preliminary research to help eliminate regrowth/reconnection of ablated areas in a Pulmonary Vein Ablation and the recurrence of A-Fib after ablation.
    He uses both RF (Radio Frequency burns) and Cryo (Freezing) ablation. He first performs a wide encirclement RF ablation of the left atrium pulmonary vein ostia. Then he supplements this with Cryo balloon ablation, which tends to freeze the veins a little bit closer to the origins of the veins. In effect he produces two parallel lines of electrical block, which reduces the chances of recovery of electrical connection between the pulmonary veins and the left atrium. This reduces the recurrence of A-Fib after ablation.
    Though this procedure has only been performed in 15 patients with reasonable follow-up, he has seen a dramatic improvement in the first time success rate for ablation of paroxysmal A-Fib. This technique is now being tested in a randomized control trial to see if the additional cost of using two technologies (RF and Cryo) is justified by a significant improvement in first time success rates.
    (Editor's Note: Dr. Shilling's innovative technique of using both RF and Cryo balloon may be a major medical breakthrough for A-Fib patients. Eliminating regrowth/reconnection and the recurrence of A-Fib after ablation may significantly reduce the need for a second ablation and improve the success rate of Pulmonary Vein Ablations.)

June 20, 2009 New comments added to the Robotic vs. Magnetic Navigation/Ablation debate at the 2009 Boston A-Fib Symposium.
    (A correspondent who wishes to remain anonymous pointed out that the Hansen robotic system does require extensive manual skill, whereas the Stereotaxis magnetic system is automated. (To this author, this is a major difference between the two systems. Even with skilled, experienced operators it is still possible with a robotic system to have misplaced ablation burns or accidents such as perforations. Whereas the magnetic system using a mouse to make the ablations seems safer, ultimately more efficient, and more capable of being used by new operators.
    The Stereotaxis system now uses an irrigated-tip catheter which is less prone to charring.)
    (Before each presentation, doctors disclose any potential conflict of interest. Dr. Natale disclosed he is a partner with Dr. Burckhardt, the CMO of Stereotaxis.)

June 19, 2009 New question answered in the FAQs section:
    "I had a single episode of A-Fib 17 months ago and was successfully converted with medication (Cardizem drip). That day I had only four hours of sleep, had eaten no breakfast, but did have an extra large coffee. I also had watery diarrhea and was somewhat dehydrated. Is it possible that my electrolytes were out of whack and led to the A-Fib episode? Other than an occasional PAC of PVC, I haven't felt any A-Fib symptoms since. I'm wondering if it's possible to have a single A-Fib attack and not have any others." (Thanks to Joan for this question.)
    Once a spot in your heart starts producing A-Fib pulses, it's usually hard to turn it off again. But whatever you did seems to have worked for you.
    Have your doctor keep track of your blood chemistry to make sure you don't get into chemical imbalances that might trigger A-Fib again. (When you went to the hospital for that single episode of A-Fib, what kind of imbalances did they find?) You may want to look into taking supplements or foods that help keep your heart chemistry in balance. (See Natural Remedies.)
    PACs and PVCs are considered benign---people with normal hearts have them. But in A-Fib they often seem to be precursors of an A-Fib attack.
    For your own peace of mind, ask your doctor for a Holter or other type of monitor which you would wear for one or three days. This would tell if you have any "silent" A-Fib which you may not be aware of, but which can be dangerous.


JUNE 13, 2009 New comments added about pacemakers:
    (The author admits to not knowing much about pacemakers. Happily one of 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 during the A-Fib, and then back to normal DDDR 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."

JUNE 13, 2009 New comments added about Defibrillators:
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."

JUNE 9, 2009 Researchers have made a medical breakthrough connection showing a strong relationship between A-Fib and the development of Alzheimer's. This finding was presented at the May 15, 2009 Heart Rhythm Society Scientific Sessions.
    In the Intermountain Heart Collaborative Study in Murray UT 37,025 people were followed for five years:
        1. Patients with A-Fib were 44 percent more likely to develop dementia than others.
        2. Younger patients with A-Fib were at a higher risk of developing all types of dementia, particularly Alzheimer's. A-Fib patients under age 70 were 130% more likely to develop Alzheimer's.
        3. Patients who had both A-Fib and dementia were 61 percent more likely to die during the study than dementia patients without A-Fib.
        4. Younger A-Fib patients with dementia may be at higher risk of death than older A-Fib patients with dementia.
    Alzheimer's is the most common form of dementia (a general term for life-altering loss of memory and other cognitive abilities), and accounts for 60-80 percent of all dementia cases today. Today Alzheimer's is the sixth leading cause of death in the US.
    "Previous studies have shown that patients with A-Fib are at higher risk for some types of dementia, including vascular dementia. But to out knowledge, this is the first large-population study to clearly show that having A-Fib puts patients at greater risk for developing Alzheimer's," according to Dr. T. Jared Bunch, the study's lead researcher.¹⁵⁴
    (Editor's Note: The study only states there is a strong connection or relationship between A-Fib and Alzheimer's, because there may be other factors influencing both the development of A-Fib and Alzheimer's. But as patients we have to assume until proven otherwise, that A-Fib causes or leads to Alzheimer's and dementia. This conclusion makes intuitive sense. In A-Fib, blood is not being pumped properly to the brain and other organs.
    Another conclusion to be drawn from this study is: therapies that leave patients in A-Fib while controlling the ventricular rate should be avoided (rate control meds like Metoprolol or Digoxin), because they may lead to Alzheimer's and dementia.)

    JUNE 7, 2009 The author apologizes to anyone trying to email me recently. He believes the email problems are now fixed. Please send your emails again.

MAY 27, 2009 Under Natural Remedies the author included a new section on Homeopathic Remedies.
    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.)

May 22, 2009 Dr. Vivek Y. Reddy will join the Mount Sinai Medical Center July 1, 2009. He previously was affiliated with the Un. of Miami, Miller School of Medicine.¹⁵¹ Dr. Andre d'Avila and Dr. Srinivas R. Dukkipati will also transfer to Mount Sinai in December. (Thanks to contributor Ray for this info.)
    Their address will be:
Cardiac Electrophysiology Laboratories
1468 Madison Av. @ 100th. St.
New York, NY 10029
(212) 241-7911

MAY 11, 2009 Some research suggests that coffee and caffeine in moderate doses may be antiarrhythmic and may reduce propensity and inducibility of A-Fib both in normal hearts and in those with focal forms of A-Fib.¹⁴³

MAY 8, 2009 PREDICTING A-FIB (For people with occasional or silent A-Fib, it is sometimes difficult to get an ECG or documentation of the A-Fib. By the time one gets to the Doctor's office or the ER, the A-Fib attack has stopped. It may now be possible to predict A-Fib simply by examining an ECG of the heart in sinus rhythm. Doctors can predict A-Fib by looking at the P wave which is formed when the atria contract. See EKG Signal.)
    The measures used to predict A-Fib are: "P-wave terminal force, P-wave duration, P-wave area, and PR duration."¹³⁹ For example, a P-wave duration of greater than 140 milliseconds is predictive of A-Fib.¹³⁸
    The study found that African Americans "seem to have more of these ECG predictors than whites, which might explain why they are at higher risk of ischemic stroke than whites, despite apparently having a lower prevalence of A-Fib." They may have intermittent or silent A-Fib which is not always detected.¹³⁹
    (Editor's Notes: The authors of the above study did not draw the following conclusions.
    Why not use the above A-Fib predictors to develop a nation-wide program to screen for A-Fib? For example, anyone over 50 could be screened by a Cardiologist looking at the patient's ECG. Anyone with A-Fib predictors, even though in sinus rhythm, could be given a Holter or other monitoring system to document if the patient has A-Fib. The A-Fib could then be treated, which would save many people from an A-Fib stroke or deteriorating heart health due to progressive A-Fib.)

MAY 6, 2009 Under "Natural" Remedies the following comments about Magnesium, Potassium, and Calcium were added:
    A deficiency in minerals like calcium, magnesium, or potassium can force the heart into fatal arrhythmias¹³³and may possibly trigger or cause A-Fib. A suggested dosage to treat arrhythmias is: 400 mg of magnesium, 500--1000 mg of calcium, and 500-1000 mg of potassium.¹³⁵(Please be advise that, before taking the above dosages, you should check with your doctor and get yourself tested to determine what are your current levels of the above minerals. Though rare, it is possible to overdose on the above minerals.)

MAY 5, 2009 An FDA advisory panel on April 24, 2009 approved the Watchman device (Atritech, Plymouth, MN) with conditions: centers implanting the device must have surgical backup, and a physician certification program must be created. The panel also recommended the creation of a registry, and extended follow-up of current trials. The FDA usually follows its advisory panel's recommendations.
     Though the vote was split 7-5, "most panel members felt the sponsor showed the device to be effective." Some panel members were uncomfortable with the size of the 800-patient study, the duration of follow-up (two or three years) and the long-term safety of the device. Some felt a decision on effectiveness was difficult when there were so few strokes in either arm. (Six patients in the control Warfarin arm had a hemorrhagic stroke, four of whom died. No one died who received the Watchman device.)
    The PROTECT-AF study on which the FDA advisory panel based its approval was a prospective randomized trial comparing closure of the Left Atrial Appendage by the Watchman occluder with long-term warfarin therapy (90% of strokes come from the Left Atrial Appendage). This was a "noninferiority" study---"the Watchman device was associated with a reduction in hemorrhagic stroke risk vs. warfarin, and all-cause stroke and all-cause mortality outcomes were noninferior to warfarin."
    Of the patients receiving the Watchman device, 87% were able to stop taking warfarin after day 45. By 12 months, 93% were off warfarin permanently.
    There were problems such as pericardial effusion in the first implantings of the Watchman device. But these decreased with experience and improved devices, training, and procedural modifications. According to Dr. David R. Holmes, Jr., current effusion rates are now around 1% and "are going to be much more what we will see as the device rolls out." Dr. Gary Abrams added, "I think that once the early morbidity from this gets worked out as people get experience with it, I think it offers an option for people who need to stay on warfarin for many, many years." http://www.theheart.org/article/962955/print.do and http://www.theheart.org/article/951777.do
    Editors Comments: This approval of the Watchman device is a major medical breakthrough for A-Fib patients.
     It is estimated that only 50% of patients who need anticoagulation protection are receiving warfarin, because it's so hard to get the right dosage or because people can't tolerate it. But most A-Fib patients can receive the Watchman device. Dr. Holmes speculated that the Watchman device might be an option for up to 70% of patients with nonvalvular A-Fib.
    Most of the panel were of the opinion that warfarin can have "devastating" effects over time. Dr. Jeffrey Brinker said, "the risk of Coumadin is high, especially in an older population who fall or who are more fragile," and who are more at risk of a hemorrhagic stroke. The Watchman device is a most welcome alternative to warfarin/Coumadin.
    Practical Consequences of the FDA Advisory Panel's Approval:
     Those of us who hate having to take Coumadin will be able to go in for a very low risk procedure that takes as little as 20 minutes, and never have to take Coumadin again! This is incredibly good news for many of us.
    Even while we are waiting for or trying to decide on having a Pulmonary Vein Ablation, we can have the Watchman inserted and then not have to worry about an A-Fib stroke.
    The Watchman device may become part of most catheter ablation procedures. If the catheter ablation procedure were unsuccessful or in case of silent A-Fib attacks after ablation, we patients would still be protected from A-Fib stroke by the closing off of the Left Atrial Appendage.

MAY 5, 2009 New info on vitamins and minerals for A-Fib. Vitamins and supplements that seem particularly helpful to heart arrhythmias are: Coenzyme Q-10, L-Carnitine, Fish Oil, Taurine, and Hawthorne Berry.
    Coenzyme Q-10's ability to energize the heart is perhaps its chief attribute. It improves arrhythmia and heart functions. Be advised that current statin drugs reduce CoQ10 levels. A CoQ10 deficiency is associated with illness and death in animals.¹³³
    L-Carnitine 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
    Fish Oil Fatty Acids (EPA, DHA, GLA) are considered by some to be natural defibrillators, lessening the incidence of cardiac arrhythmias and A-Fib.¹³⁶
    Taurine 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
    Hawthorne Berry reduces tachycardias and palpitations and prevents premature ventricular contractions (PVCs). Hawthorne can energize the heart without prompting arrhythmias. It has a normalizing effect upon the heartbeat.¹³⁷

march 28, 2009 The AFIB REPORT by Hans Larson has the following caution about digoxin. "Recent research has clearly shown that digoxin should not be used on a continuous basis in patients with paroxysmal lone A-Fib, since it is likely to worsen their condition and result in it eventually becoming permanent.^{"(No References Cited)} And, "Digoxin poisoning is a leading cause of hospital admissions with anywhere between 10 and 30% of patients on the drug being hospitalized for digoxin intoxication."^{(No References Cited)131}

March 21, 2009 Dronedarone (brand name Multaq) was recommended for approval by an FDA advisory committee (March 18, 2009). It isn't guaranteed that the FDA will approve dronedarone, but it usually doesn't disagree with its committee's recommendations.
    (This is a major medical breakthrough for A-Fib-ers, especially for older patients, for those who can't have a Pulmonary Vein Ablation or a Mini-Maze surgery, or for those who have failed these procedures/surgeries. Dronedarone may allow many of these A-Fib-ers to lead a relatively A-Fib free life.
    Dronedarone is similar to amiodarone which is considered the most effective anti-arrhythmic drug, but without its toxic side effects. In the ATHENA clinical trial, Multaq (by Sanofi-aventis) was the only anti-arrhythmic drug "to have shown a significant reduction in morbidity and mortality in patients with A-Fib/A-Flutter..." ) http://news.prnewswire.com/ViewContent.aspx?ACCT=109&STORY=/www/story/03-18-2009/0004991096&EDATE

February 16, 2009 A-Fib.com complies with the HONcode standard of trustworthy health information on the internet. (The Health on the Net Foundation in Switzerland tries to guide lay users and medical professionals to reliable sources of health-care information online. This HONcode accreditation indicates that A-Fib.com has been deemed a reliable source of health information and meets standards, including those related to the qualification of the authorities cited, privacy of personal data submitted by a visitor to A-Fib.com, and financial disclosure of funding sources. It does not guarantee that all the health information on A-Fib.com is infallible.)

July 17, 2008 The FDA recently approved the new beta blocker drug nebivolol (brand name Bystolic by Forest/Mylan, a selective beta-1-blocker)).¹²⁶ This is a minor medical breakthrough for A-Fib-ers taking traditional beta blockers like atenolol or metoprolol who may feel tired or fatigued due to slower blood flow. (Traditional beta blockers reduce the effect of excitement and physical exercise on heart rate and force of heart contraction.) Nebivolol is an effective beta blocker that also produces vasodilation (an expansion of the blood vessels) and reduces peripheral resistance by increasing nitric-oxide release. Instead of slowing blood flow, nebivolol maintains blood flow and lowers vascular resistance.
Nebivolol is similar to the newer beta blocker carvedilol (Coreg), though they act differently. (Carvedilol is a non-cardioselective beta 1, beta 2 and alpha-receptor blocker, whereas nebivolol is highly cardioselective [blocking beta 1 receptors only] and produces vasodilation by nitric-oxide release.)

June 27, 2008 "Dronedarone safety, efficacy standings bolstered in huge A-Fib trial." Dronedarone (brand name Multaq by Sanofi-Aventis) is a drug in clinical trials to replace amiodarone which often has serious toxic side effects. Both drugs have similar molecular structures and seem to work in a similar way. But dronedarone (a benzofuran analog of amiodarone) doesn't have the iodine component that is largely responsible for amiodarone' s toxic effects on the lungs, thyroid, eyes and other organs.
In the randomized ATHENA trial over 4,500 A-Fib patients in 37 countries took either dronedarone or a placebo in "the largest antiarrhythmic drug trial ever conducted." Patients who took dronedarone experienced a 24% drop in risk of Cardiovascular (CV) hospitalizations or death over almost two years. Unlike other antiarrhythmic drugs, dronedarone seems to carry a low risk of adverse events. Secondary clinical end points also improved, such as less hospital admissions for A-Fib and acute coronary syndromes. According to Dr. Bramah N. Singh of UCLA, "...in terms of safety, it (dronedarone) is the best drug we have for atrial fibrillation." See http://www.theheart.org/article/867591.do.
The trial did not compare the efficacy of dronedarone to amiodarone, which is the subject of another ongoing randomized clinical trial called DIONYSUS.

June 16, 2008 A new advancement in mapping techniques may significantly improve ablation treatments. A specialized multielectrode mapping catheter with a 20-pole penta-array produces rapid, high-density atrial mapping. The whole atrium can be mapped in less than 8 minutes. It is used with an Ensite NavX mapping system. See: http://circep.ahajournals.org/cgi/content/abstract/1/1/14

June 12, 2009 Southeast Regional Research Group, Columbus and Savannah, GA is looking for volunteers to participate in a medical research study comparing Coumadin with a new anticoagulant. Patients must be taking Coumadin and have high blood pressure, congestive heart failure or diabetes. Qualified participants must be 18 years or older and will receive study related procedures and medication at no cost, and receive stipends that help with transportation to and from appointments.

June 11, 2008 Summary of Dr. Carlo Pappone's presentation at the 2008 Boston A-Fib Symposium and a comparison of Drs. Pappone's, Haïssaguerre's and Reddy's different stepwise approaches to treating Chronic A-Fib: Biatrial Catheter Ablation for Chronic Atrial Fibrillation

Akron General Medical Center
2500 Metro Health Dr.
Cleveland, OH 44109
Dr. Andrea Natale (has moved to Texas Cardiac Arrhythmia, P.A. but works at Akron General on a as-needed basis---call Dr. Robert Schweikert, 330-344-4377 for further info)

MetroHealth Medical Center
2500 Metro Health Dr.
Cleveland, OH 44109
Dr. Andrea Natale (has moved to Texas Cardiac Arrhythmia, P.A. but works at MetroHealth Medical Center on an as-needed basis---for further info contact Dr. William Lewis, 216 778-2249)

November 27, 2007 New question answered in the FAQs section: "I take atenolol, a beta-blocker. Will it stop my A-Fib."

November 20, 2007 The Pill-In-The-Pocket treatment. How some people use high doses of an antiarrhythmic med to shorten the duration of an A-Fib attack.

October 19, 2007 The A-Fib community is shocked to learn that the Cleveland Clinic did not renew Dr. Andrea Natale's contract. There is no word yet where Dr. Natale will work, or where A-Fib patients can be treated by him. For more information see http://www.cleveland.com/news/plaindealer/index.ssf?/base/news/119131405528890.xml&coll=2 . You can leave messages for Dr. Natale at his E-mail address andreanatalemd(at)gmail(dot) com.

August 14, 2007 A somewhat controversial study gives actual odds for getting an A-Fib stroke depending on overall heart health and whether one is taking aspirin or warfarin.

July 18, 2007 A WORD OF CAUTION REGARDING WEB SITES WITH A-FIB INFORMATION:
Some web sites for A-Fib patients may be biased toward a particular technique or approach, often because of financial, political, or other ties to medical devices manufacturers, pharmaceutical companies, hospitals, doctors, or other organizations. The author recommends, when searching the Internet for info on A-Fib, you ask yourself, "Who is paying for this web site, and what is their agenda?"
(The author of A-Fib.com strives to offer unbiased info on all A-Fib treatments, but admits to enthusiasm for the catheter ablation procedure (PVA[I]). He was cured of his A-Fib in 1998 by at PVA(I) procedure in Bordeaux, France. However, he has no financial ties, receives no remuneration or grants, and has no affiliation with anyone or any organization.)

May 25, 2007 LOCAL A-FIB SUPPORT GROUPS FORMING
For further info contact Joyce at jarintime(at)yahoo.com (the @ is written as "at" to prevent access by spam mailing lists).

April 13, 2007 New story in the Personal Experiences section 25 YEARS IN A-FIB.

February 3, 2007 Update/summary of the 2006 Boston A-Fib Symposium by Drs. David Keane, Vivek Reddy and Jeremy Ruskin. (This update is written by doctors for doctors and may be somewhat difficult for patients to read. However, it is an excellent summary not only of the main points of the 2006 Symposium but of all the issues of concern to A-Fib patients today.)

January 27, 2007 Overview #4 of the 2007 Boston A-Fib Symposium. Doctors discuss their most difficult and/or least successful cases, and two ablation cases were presented live via satellite.

January 26, 2007 Overview #3 of the 2007 Boston A-Fib Symposium. Insurance not adequately compensating for complicated A-Fib ablations, and the new atrial-selective medication Ranolazine.

January 25, 2007 Overview #2 of the 2007 Boston A-Fib Symposium. New Research and Medical Developments in A-Fib: The Possible Importance of Ganglionated Plexi Sites in A-Fib, Randomized Clinical Trials of the CryoAblation Balloon Catheter, The Importance of the 95% Success Rate of Curing Persistent A-Fib reported by the French Bordeaux Group.

November 1, 2006 Stereotaxis Announces Initial U.S. Clinical Usages of Cardiac Ablation Catheter with Company's Niobe(R) System. The Niobe system utilizes a computer-controlled magnetic field to remotely steer a magnetic ablation catheter that applies a consistent, "soft-touch" contact with the heart which may reduce the risk of perforation during ablation procedures.⁹⁴

October 21, 2006 A study comparing the Pappone Circumferential Anatomical PV Isolation procedure with an integrated approach using both the Pappone method followed by a Segmental ablation (with electrophysiological confirmation of PV disconnection) was found to be more effective than the Pappone method alone. "Electrophysiological confirmation of PV disconnection could be a useful marker of successful RF treatment of A-Fib."⁹³ (Thanks to Dick Inglis for this info.)

October 14, 2006 In a major medical breakthrough the French Bordeaux group reported a 95% success rate in curing Persistent/Chronic A-Fib.⁹² See Jaïs Chronic A-Fib. (Thanks to Dick Inglis for this info.)

August 5, 2006 According to a Wall Street journal article by David Armstrong, four patients are known to have died after having the ArtiCure (Wolf) Mini-Maze surgical operation to cure A-Fib.⁹¹

August 5, 2006 According to a Wall Street Journal article by David Armstrong, surgeons at the Cleveland Clinic may have or may have had extensive financial ties to manufacturers of medical equipment these surgeons use to treat A-Fib patients.⁹¹

August 4, 2006 Sleep apnea may be a trigger or cause of A-Fib, and may be cured in some patients by treating the sleep apnea.⁹⁰

June 11, 2006 Dr. Andrea Natale and the Cleveland Clinic now call their catheter ablation procedure to cure A-Fib "Pulmonary Vein Antrum Isolation (PVAI)." This procedure still involves making circumferential lesions around the outside of the PV openings.

June 11, 2006 Low-dose steroids have been reported to prevent recurrence of A-Fib, possibly because they suppress systemic inflammation.⁸⁵

June 6, 2006Patients having an A-Fib attack can use a pill-in-the-pocket approach to self administer the antiarrhythmic drugs flecainide or propafenone to stop the attack.

April 26, 2006 A moving story about a father's death Toxic Effects of Amiodarone? in the Personal Experiences section.

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

Santangeli, P, Di Biase, L, et al. "Transseptal access and atrial fibrillation ablation guided by intracardiac echocardiography in patients with atrial septal closure devices." Heart Rhythm. 2011 Nov;8(11):1669-75. Epub 2011 Jun 22.

OBESITY, SLEEP APNEA AND A-FIB

NSAIDs -- The Unintended Consequences Dynamic Chiropractic October 20, 1997, Volume 15, Issue 22 by Alan Cook, DC

NSAID use associated with risk of atrial fibrillation or flutter

NSAIDs and atrial fibrillation BMJ 2011; 343:d2495 doi: 10.1136/bmj.d2495 (Published 4 July 2011)

NSAIDs -- The Unintended Consequences Dynamic Chiropractic
October 20, 1997, Volume 15, Issue 22 by Alan Cook, DC

NSAIDs and atrial fibrillation
BMJ 2011; 343:d2495 doi: 10.1136/bmj.d2495 (Published 4 July 2011)