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Arrythmias&Heartbeat Conditions

February 26, 2013
Noon – 1 p.m. (EST)

Jose Baez-Escudero, MD
Cardiologist

Cleveland_Clinic_Florida_Host: Today's Live Web Chat, "Arrhythmias and Heartbeat Conditions" with Jose Baez-Escudero, MD will begin at 12 noon EST. Please submit your questions by typing them below and then clicking 'Ask'.

Cleveland_Clinic_Florida_Host: Welcome to our Online Health Chat "Arrhythmias and Heartbeat Conditions" with Jose Baez-Escudero, MD. We are thrilled to have him here today for this chat. Let’s begin with the questions.

Jon_Silks: Arrhythmias and Heartbeat Conditions on 02/26/2013. What can you tell us about the new breakthrough treatment for AFIB announced back in July of 2012 by UCLA?

Dr_Baez-Escudero: Therapy for atrial fibrillation remains suboptimal, largely because of uncertainty in its mechanisms. You’re referring to ablation at sources of atrial fibrillation identified as focal impulse and rotor modulation, or “FIRM”. This technique was initially developed by Dr. Narayan at UCSD in San Diego. In a minority of cases it has proven to acutely terminate atrial fibrillation and render it non-inducible, often with very brief delivery of ablation energy. This technique uses contact panoramic mapping of the arrhythmia and theoretically can increase a single procedure success by more than 70% in patients with paroxysmal atrial fibrillation. Although promising results have been shown in small trials, the long-term outcome of this type of ablation has not been studied yet, mainly because it is new. We will see the results and applicability of this technique in the next 2 or 3 years.

Moderatror: Please note that questions submitted before the chat will be answered in the order they were received.

Cleveland_Clinic_Florida_Host: I had a cryoablation in Nov. 2011 and fibs stayed away for one year. Now I am having Fibs whenever I swallow or eat anything. These fibs make me dizzy and sometimes I have to hold on to something to steady my balance. Why would Fibs occur when I am eating or swallowing?

Dr_Baez-Escudero: Atrial fibrillation can be triggered in some occasions by different stimuli within our own body, particularly from regions associated with the vagal nervous system. When we swallow and eat, some nerves cause a reflex that affects the autonomic influence from the nervous system in the heart. This can trigger an arrhythmia. There is no established relationship of this phenomenon to a previous ablation. Although cryoablation has been well studied and has similar outcomes to regular radiofrequency ablation, recurrences after the first ablation are not uncommon and are usually do to pulmonary vein reconnection. Patients often require a second touchup procedure to completely eliminate the arrhythmia. Consultation with your electrophysiologist is warranted.

eDavid: Last week I had a cryoablation for my paroxysmal atrial fibrillation. It was discovered over a year ago and prior to that I was rather healthy, No meds/prescriptions needed. During the prep it was discovered via a CT scan that I have an ascending aorta aneurysm measuring 4.3cm. What should I expect and what happens next? Not even seen the cardiologist, post-op yet. What are the treatments? What kind of surgery might follow? Should I continue with normal routines like exercising vigorously?

Dr_Baez-Escudero: The ascending aortic aneurysm found is an incidental finding, commonly seen in patients with long-standing hypertension. The size of your particular aneurysm appears to be non-surgical, meaning surgery is not likely to be needed to fix it for now. Surgery for aortic aneurysms is beyond the scope of my practice as an electrophysiologist. I would recommend that you follow up with your electrophysiologist for your ablation and arrhythmia issues, but also with general cardiology to have follow up CT scans and ultrasounds of your aorta. It is also recommended that you have a postoperative evaluation with your electrophysiologist within 4 weeks after the initial ablation.

nance: In 1998 I had mitral valve repair (by Dr. Cosgrove) and have done well. However, last Nov., I was hospitalized with sudden atrial fibrillation apparently brought on by Zyrtec D or, possibly, a too high dose of Snythroid. I firmly believe the cause was the decongestant. I was cardioverted and am in normal sinus rhythm. Zarelto, 15 mg. is only med I am taking. Will I be able to stop the anti-coagulant if I remain in normal sinus rhythm? Thank you.

Dr_Baez-Escudero: Is not uncommon to have atrial fibrillation in patients with prior valvular disease, even years after surgery. Although certain triggers such as the use of decongestants are common, prior valve disease makes a perfect substrate for atrial fibrillation to reappear. Whether you have to continue anticoagulation or not will depend on other risk factors for stroke that you may have, such as hypertension, diabetes, low ejection fraction, a history of prior stroke, and if you're older than 75 years old. Continued rhythm monitoring after the initial cardioversion is also recommended.

stockpart: had an episode of Ventricular Tachycardia in December 2011. I am 42 years old. I was told that my ejection fraction was 28-30%. I received an implantable ICD. I am on Solothol, Analapril and Coreg. I have been an athlete all my life. I play competitive racquetball. I have eased back into my exercise routine. I am now lying at a high level again. My question is, is it safe to play? Why do I not have any symptoms or a heart issue? I believe I should be used as a study on heart issues and exercise recovery.

Dr_Baez-Escudero: Defibrillator therapy was certainly indicated at the time of your initial ejection fraction measurement. However it seems that you have class I heart failure symptoms, which is basically asymptomatic congestive heart failure. It is likely that with the medications that you received such as Enalapril and Coreg, your heart function might have improved. Exercise is routinely recommended as tolerated for patients with congestive heart failure. It is likely that despite the fact that your ejection fraction is low, because you have been in good shape, you are well compensated and able to maintain adequate levels of perfusion during exercise. You should see your heart failure specialist or general cardiologist in order to clear you for high level exercise such as competitive racquetball.

BEBOPPER: I have been diagnosed as having atrial fibrillation. I was prescribed Diltiazem, Metaprolol and then Lanoxin. I had reactions to the first two and the Lanoxin did not work as was expected. I continue to have light chest pain. Any suggestions?

Dr_Baez-Escudero: The 3 medications you describe aren't used to slow down the rate during atrial fibrillation. If you are unable to tolerate Diltiazem or Metoprolol, it is unlikely that the Digoxin alone will work. Consultation with electrophysiologist is recommended in order to assess the need to restore normal sinus rhythm with possibly a cardioversion. This may obviate the need to take some of these drugs. Chest pain is not a typical symptom of atrial fibrillation and needs further workup.

theehmann: After my heart attack 18 months ago I also had A-fib and was on Amiodorone. I was taken off of it 4 months ago and have no medication to prevent A-fib. Is there a medication w/ minimal side effects that I could take in place of Amiodorone? Thank you.

Dr_Baez-Escudero: There are several antiarrhythmic drugs that we routinely use in order to prevent atrial fibrillation. If you've have had a heart attack, you likely suffer from coronary artery disease. This will prevent us from using certain drugs such as flecainide or propafenone. Assuming you have a normal renal function, drugs such as sotalol or dofetilide can be used and are very good at preventing atrial fibrillation. A similar drug to amiodarone is available as well called Dronedarone. The real question is whether you will have a recurrence of atrial fibrillation and whether you will require long-term antiarrhythmic therapy. Consultation with an electrophysiologist is warranted.

MPJBM: I had Maze procedure 6 months ago. I wore the holter monitor and there is no AFib at this time. I have had a previous TIA before I was diagnosed with A fib. My question is, Should I stop taking Coumadin?

Dr_Baez-Escudero: Whether you have to continue anticoagulation or not will depend on other risk factors for stroke that you may have, such as hypertension, diabetes, low ejection fraction, and if you're older than 75 years old. In general patients that have had a prior stroke or TIA are considered high risk and we generally recommend to continue long-standing anticoagulation. Continued rhythm monitoring after the initial cardioversion is also recommended, maybe for a longer period of time with a 30 day event monitor. Another important question to ask your surgeon is if you had a left atrial appendage removal or ligation at the time of the Maze procedure. If your left atrial appendage was removed or ligated, your risk of stroke is very low and you could potentially stop taking long-term anticoagulation.

eadler1220: Two questions: 1)Any issues with long term use of Inderal/Propranolol? I understand it is not a targeted beta-blocker, and there are newer and better ones on the market. 2) I was diagnosed with A-Fib about 7 years ago. Would you suggest a re-evaluation, and if so, should it be done by a cardiologist or an electro-physiologist?

Dr_Baez-Escudero: It depends on what the indication for Propanolol is. If you suffer from congestive heart failure this may not be the right beta blocker for you. There are superior beta blockers that we use for rate control in atrial fibrillation. In general beta blockers are well tolerated and there are no potential long-term side effects. I believe anybody with a history of atrial fibrillation should be evaluated periodically with an electrophysiologist.

Elizabeth_Ross: I am a 50 y/o woman, diagnosed with Cardiac Sarcoidosis, arrhythmia and cardiomyopathy in 2009, without any biopsies. I have had no known issue in my lungs, some lesions on my face which responded to Diflucan and a yeast-free diet. I received an ICD and had no incidents until April, 2012, when I had one 7 1/2 hour VT at 188 bpm, but my ICD was set at 193, so it never treated, and last month several short VT's were paced out and then fired, then a few more paces before returning to normal sinus rhythm. What is the best test to find proof of granulomas and/or progression of the disease? I had a Pet Scan in 2009, but the report did not indicate granulomas, just inflammation and 'likely' Sarcoid.

Dr_Baez-Escudero: Great question. The best test to find proof of cardiac granulomas in cardiac sarcoid is a cardiac MRI. Unfortunately this cannot be performed in you because you already have a defibrillator. Patients with ICDs cannot have cardiac MRIs. We commonly use PET scans, and these will not indicate granulomas. However if the PET scan was positive for inflammation, it is likely that the sarcoid is still active in your heart and possibly progressing. This also goes along with the development of new ventricular tachycardias. If you have ventricular tachycardias that are slow, these can potentially be mapped and ablated, further preventing shocks and antitachycardia pacing. I recommend you follow-up with your electrophysiologist to consider VT ablation.

Jacque_Jensen: I'm 53 yr old female, I'm very active and workout regularly. I went into A Fib after I went home from arthroscopic knee surgery. I failed to convert after 3 rounds of amnioderone in the ER. I was cardioverted the next day. I have a trip planned in Peru that covers a 15,300' pass. I've been over 18'000' last year with no issues. How safe would it be to make this trip in 3 months? I've never had any cardiac problems in my life. Would this be considered a "pre-exsisting" condition now that it has happened only once?

Dr_Baez-Escudero: Postoperative atrial fibrillation is very common. Occasionally it can sustain and require cardioversion. Your risk of developing atrial fibrillation in the future as you get older is higher than the general population, because you have already sustained an episode and required cardioversion. This means that although the trigger for it was likely to be the stress from surgery, you have a substrate and that is able to sustain the arrhythmia. High altitude elevation should not be a trigger for your arrhythmia. A single occurrence of postoperative atrial fibrillation may not be considered a pre-existing condition. Consultation with electrophysiology prior to your trip may be warranted in order to assess the need for continuous antiarrhythmic therapy.

Alyssa_Q: Hello, I am a 22 year old female, not overweight, and healthy eater. I am a smoker, but no alcohol, caffeine, or drug use. I was diagnosed with WPW in 2008 and with a successful ablation. In 2010 after the birth of my son I started having health problems again. I have had 3 Electrophysiology studies and all show no extra pathways or dangerous rhythms. They implanted a medtronic loop recorder that they interrogate regularly that always shows alternating brady episodes or episodes of SVT/ atrial tachycardia.I have now been diagnosed with a remedy of things but what it comes down to is I have POTS, PSVT, SVT, and atrial tachycardia and occasional atrial fib that are not related to the POTS. Also possible medically induced long QT. However Beta blockers are not a option as my heart drops into the 30's naturally without meds. . They have considered tachy-brady syndrome, but are not sure. However my cardio will not do a pacemaker as he feels a anti arrhytmic drug would be best to try first. I however have drawn the line and feel the benefits do not outweigh the risk. So i guess my questions are, what line of treatment would you recommend in general? Also are any of these rhythms dangerous?

Dr_Baez-Escudero: The 4 rhythms that you have mentioned: PSVT, SVT, atrial tachycardia and atrial fib are generally not life-threatening. Treatment of these is predicated by the severity of symptoms, and how much they affect your quality of life. You are too young to receive a pacemaker and antiarrhythmic drugs may be warranted in your particular case. Therapy of POTS can sometimes be challenging. I recommend establishing a relationship with one electrophysiologist and routine follow-up.

PVC44: Hello, I am a 45 year old male with a pacemaker due to syncope. Last year, I had 2 catheter ablations for PVC's and NSVT. After the 2nd ablation, my resting heart dropped 20 bpm and my bp also dropped to the normal range. Is it normal for the heart rate and bp to decrease after an ablation? Also, I am having PVC's again with dizziness plus cold hands and feet. Are cold hands and feet a symptom of arrhythmias? Thanks.

Dr_Baez-Escudero: It depends on where the PVC and SVT was ablated. It is unclear whether the pacemaker was inserted after the ablations. If the ablation was performed and an area close to the sinus node or AV node, your heart rate can drop as a consequence. If you continue to have PVCs in a pattern of bigeminy, which is a PVC after every other normal heartbeat, this will effectively cut you’re your heart rate in half causing “pseudo-bradycardia”. If your heart rate is half of normal you may experience cold hands and feet as a result of poor perfusion of your organs.

janine: Hello, my daugther is 19 years old and she was diagnosed with Wolff Parkison White syndrome, the doctor recommended us to make her an ablation but unfortunately we lived in Honduras and that type of procedure dosen't exist here because there is no physiologist that can practice the procedure, so he prescribed her 1/2 tab of Inderal daily; So I would like to know if it will be better to make the ablation to her and the cost of the procedure?

Dr_Baez-Escudero: Your daughter has a very treatable condition and ablation therapy can be curative. This will allow her to the live her normal life without the need for continued medication. Inderal is not very effective at preventing episodes of tachycardia in patients with WPW. I strongly recommend you come to see us at the Cleveland clinic Florida which is located minutes from Miami. All 3 electrophysiologists here speak Spanish fluently. You can fly directly from Tegucigalpa. I will have my international department contact you to give you an estimate of the cost of the procedure.

pabestco: Good morning, I was in perfect health in 1999 and suddenly one day my heart started beating really fast and hard. This condition has lasted from then to now on a regular basis up to last night. It sometimes comes with pains in the feet and shoulder and back of the neck. There is always dizziness and discomfort and shortness of breath. I was diagnosed with MVP then told it was not MVP ran many tests and all came out clean, can you help please?

Dr_Baez-Escudero: Mitral valve prolapse was commonly diagnosed in people with palpitations, without really having a clear-cut correlation with any arrhythmia. Her symptoms are suggestive of supraventricular tachycardia or possibly atrial fibrillation. It is imperative that you have a cardiac Holter monitor in order for a cardiologist to identify the rhythm problem during one of the episodes.

chuckarc: My mom occasionally has bouts of tachycardia which last for hours. She is on 100mg of Tenormin per day. What is the cause of tachycardia that lasts many hours? She has mitral valve prolapse and an ascending aortic aneurysm. Her BP drops with the Tenormin but her HR drops slowly. What should she do? How low can the HR go before she has to worry?

Dr_Baez-Escudero: Again, mitral valve prolapse was commonly diagnosed in people with palpitations, without really having a clear-cut correlation with any arrhythmia. Her symptoms are suggestive of supraventricular tachycardia or possibly atrial fibrillation. Both of these arrhythmias can last for hours and stopped spontaneously. It is imperative that she wears a cardiac monitor in order for a cardiologist to identify the rhythm problem during one of the episodes. Beta blockers such as Atenolol can be used to treat these arrhythmias. The side effect is bradycardia when the arrhythmia is not occurring. The heart rate may drop to 40-50 beats a minute, and as long as she has no symptoms such as dizziness or passing out, the actual number of beats does not matter. If she received appropriate therapy for either supraventricular tachycardia or atrial fibrillation she may not need to take the Tenormin on a regular basis.

Cleveland_Clinic_Florida_Host: We are getting ready to close for today. A large number of questions were received and we apologize if we did not get to your question. We will try to answer as many questions as possible in these last few minutes.

Cleveland_Clinic_Florida_Host: This web chat transcript will be available in two weeks. The questions that were not answered live will be answered by Dr. Baez-Escudero and included in the transcript.

Cleveland_Clinic_Florida_Host: If you have additional questions, please go to clevelandclinic.org/health/livepersonchat to chat online with a health educator.

Cleveland_Clinic_Florida_Host: If you would like to view the entire transcript of this chat it will be available in about two weeks on the Cleveland Clinic Florida website at http://my.clevelandclinic.org/florida/about/web-chats.aspx.

johnknuth: Heart Attack on October 1, 2011 (extensive myocardial infarction, coma 4 days, 5 stents with no re-flow), I maintained a healthy lifestyle. I have always maintained my weight, exercised every day, eat a heart healthy diet before and after my HA, had low BP and good Cholesterol readings. My Lipoprotein (a) is 56.7. I now have an ICD and have A-Fib. My EF is around 30. My medicines are the following: 1000 mg Niacin, 150mg Pradaxa, 10mg Coreg Cr, 5mg Altace, 25mg Aldactone, 75mg Plavix, 81 mg Aspirin, 10 mg Lipitor My Questions: Should I try to increase my Coreg to decrease my A-Fib or try another medication? (I have been sensitive to Beta Blockers) Should I still be on both Plavix and Pradaxa because of my risk of stroke?

Dr_Baez-Escudero: You certainly need to continue to take the Coreg which needs to be titrated to an optimal dose as tolerated. This is not used to decrease atrial fibrillation but rather to improve your pumping function of the left ventricle. It is unlikely that the beta blocker effect of Coreg will have any effect on your atrial fibrillation. The only 2 drugs that you could use are Dofetilide or Amiodarone, assuming that your kidney and liver function is normal. If you received 5 stents you likely need to be on Plavix for life. You are also high risk for stroke with atrial fibrillation and full anticoagulation with Pradaxa is also indicated. Although you are at higher risk of bleeding with the combination of Plavix and Pradaxa, unfortunately you should be on both for now. It is possible that continuous interrogation of your defibrillator can determine your atrial fibrillation burden which will allow your electrophysiologist to decide whether or not to stop anticoagulation in the future, particularly if you are on continuous antiarrhythmic therapy or undergo catheter ablation of atrial fibrillation. You may also be a good candidate for upcoming technologies such as atrial appendage occluders or excluders. This will theoretically allow you to discontinue the Pradaxa.

RGambatese: Would you please clarify your answer to Nance who had AFIB related to a valve disease problem is taking Zarelto. I thought Zarelto was not indicated for patients whose AFIB was related to a heart valve issue? I find this very confusing. Would you please clarify particularly with all the ads for Pradaxa and other similar drugs? Thanks.

Dr_Baez-Escudero: All of the new anticoagulants on the market have not been studied in patients with valvular heart disease. In general the group of patients labeled as having atrial fibrillation related to “valvular heart disease” are patients to suffer from mitral stenosis. This condition causes changes in the left atrium that predispose patients to stroke the most. The reason why we cannot use any drugs in patients with valvular atrial fibrillation is mainly because these groups of patients are considered high-risk in have not been studied. Atrial fibrillation in the setting of mitral regurgitation and having a mitral valve repair is usually not considered as a valvular afib. The other group of patients that can not take the newer drugs are patients that have had mechanical valve surgery. For patients with mitral stenosis and also mechanical valves the only anticoagulant that can be used is Warfarin.

Cleveland_Clinic_Florida_Host: I'm sorry to say that our time with Jose Baez-Escudero, MD is now over. Thank you again, Dr. Baez-Escudero for taking the time to answer our questions today about Arrhythmias and Heartbeat Conditions. To make an appointment with Dr. Baez-Escudero, or any other specialist at Cleveland Clinic Florida, please call 877.463.2010. You can also visit us online at vanity clevelandclinicflorida.org.

Neptune: I am taking Bystolic after a heart ablation. For some reason this drug is classified as non-formulary and the co-pay is high. Express Sc. wants one to fail a generic before allowing a brand name drug at a lower co-pay. Have the physicians at Cleveland Clinic had any problems with Bystolic. Why non-formulary?

Dr_Baez-Escudero: Bystolic is a beta blocker used for hypertension. As any new drug it is expensive. Generic beta blockers may not be as effective as Bystolic but may be tried, such as Metoptolol or Atenolol.

BigHeart123: My doctor (cardio specialist) has said I have Ventricular Tachycardia, how serious is this? Is it more dangerous to treat the right ventricle?

Dr_Baez-Escudero: Ventricular tachycardia is generally serious, particularly in the setting of a weak heart muscle. There are some types of ventricular tachycardia that occur in normal hearts that are relatively benign. They can come from both the right and left ventricles. You should have a full evaluation by an electrophysiologist, and follow his/her recommendation.

Nutzy: I had undergone in December 2002 a mitral valve replacement (mechanical) )and MAZE PROCEDURE for atrial fibrilation. Several cardial conversion and tried almost every antyarrhitmic drugs(not Dophetilyde).Every drug worked for awhile .Now after approximately ten years my Atrial fib became permanent and my cardio put me on drugs for rate control: Bisoprolol 10mg twice daily, Diltiazem 180mg daily Valsartan 80mg and Lipitor 20mg and Warfarin. Sometimes very symptomatic with the Atrial fib. I felt better with the antyarrhythmic treatment. I need to mention also that I have from2008 adouble chamber pacemaker. What is your advice? I don't feel very good with the combination of beta blocker and calcium channel blocker. Could you thing in my case about different treatment? I am 67 years old.

Dr_Baez-Escudero: You have a complicated long history of arrhythmia. Some skilled electrophysiologists may offer you ablation therapy to “touch up your MAZE” which could offer you a chance for normal rhythm. This is unlikely to work without an antiarrhythmic. You are too young to be on chronic amiodarone therapy. Perhaps you should consider AV node ablation and upgrading your current device to a biventricular pacemaker. This will allow you to get rid of all rate controlling drugs, but will make you pacemaker dependent.

William_sear: I have been diagnosed with AFIB and am taking a beta blocker with a blood thinner (Pradaxa). I would like to substitute natural blood thinning foods and supplements for the Pradaxa (fish oil, aspirin etc). Is this a feasible course of action?

Dr_Baez-Escudero: No natural known blood thinning foods have been studied in atrial fibrillation. If your cardiologist prescribed Pradaxa you were probably deemed to be high risk for stroke, and therefore anticoagulation with a FDA approved well studied drug is needed. The options are Warfarin, Pradaxa, Xarelto and Apixiban.

Lori_Cherry: I have ventricular tachycardia- really bad have had for 6 years - had an ablation in May, 2012 it did not work- I am wondering if a pacemaker will help.

Dr_Baez-Escudero: Pacemakers do not prevent ventricular tachycardia. Depending on what kind of VT you have you may need a defibrillator to prevent sudden death. Antiarrhythmics or a second attempt at ablation are your best options.

Nancy_Moody: Wanting to discuss options to cure my SVT besides prescription medications. They are no longer working for me as well as they did 6 yrs ago when I started on it.

Dr_Baez-Escudero: Most SVTs are curable with catheter ablation. In skilled hands of an electrophysiologist, SVT ablation is performed as an outpatient procedure with >90% success and very short recovery time, with minimal risk. You should have a full evaluation by a cardiac electrophysiologist.

Ed_Mack: I have a question regarding electrophysiology. With regards to the ablation procedure for afib, what is the purpose of tilting the patient head down with feet higher than head during the procedure?

Dr_Baez-Escudero: I have never heard of such practice unless your doctor or anesthesiologist was trying to put a central line or catheter on your neck veins. That maneuver increases blood return to the head making it easier to find a vein with a needle.

santanup: How to get well from paroxysmal ventricular tachycardia? Is their any risk in paroxysmal ventricular tachycardia?

Dr_Baez-Escudero: It depends whether you have a structurally normal ventricle or a sick ventricle. Ventricular tachycardias in normal hearts are usually not life threatening. If you have congestive heart failure, ventricular arrhythmias can be lethal. You should have a full evaluation by a cardiac electrophysiologist.

Chickie: I had an ablation about a week ago, went well only took about an hour or so. But I have been feeling a little tired, shortness of breath and having some irregular heart beats, is this normal and how long can this last? I have a fu appointment in two weeks with doctor.

Dr_Baez-Escudero: Without knowing what kind of ablation you had it is hard to determine if the symptoms you are experiencing are related to the procedure or not. I recommend to have routine follow up with the doctor that did your procedure.

yless1: I had a cardiac ablation in October. It seems to have worked on the irregular heartbeat but my heart is still pounding. Mr report reads Hyperdynamic left ventricular systolic function. EF 75%. Do I have a separate problem or should the ablation have corrected this?

Dr_Baez-Escudero: A hyperdynamic left ventricle is not caused by a rhythm problem. all that hyperdynamic left ventricular systolic contractility means is that your heart’s ejection fraction (how much the heart muscle, or in this case your left ventricle can contract or squeeze to eject blood from your left ventricle out systemically) is higher than normal (a normal EF (ejection fraction) is roughly around 55-65%. This is generally related to the level of hydration your body had and the autonomic tone at the time they did the echocardiogram. It is not a pathologic finding.

Liesel:I have had 7 A-Fib episodes in two years. It always happens during rest. Pulse raced from a resting heart rate of 50 to between 120-180; takes from 2 -6 hrs. to revert to sinus rhythm. I take Plavix, 81 mg Aspirin, 25 mg Metoprolol succrete ER, Crestor 10 mg. Heart history: MI, 2 bare metal stents in LAD, 1 DES stent first marginal. I do have moderate mitral valve prolapse. During these A-Fib episodes I chew 1-2 whole Aspirin, take 1-2 Xanax, 1 Metoprolol (but the faster acting tartrate). Question: Is there anything else I could be doing to shorten the episodes, also is it a good idea to even take the Aspirin? I was thinking that would prevent a stroke. I am 73 years old. I exercise daily and live and eat very healthy.

Dr_Baez-Escudero: There are several options that could be used to the shorten the duration of the episodes and also decrease the frequency of the episodes. You may be a good candidate for antiarrhythmic drugs and possibly catheter ablation of atrial fibrillation. Given your risk profile you are more likely to fall in the intermediate risk category for stroke. Despite the fact that you are taking Plavix and aspirin, taking additional aspirin at the time of an episode has not been shown to decrease the risk of stroke. You most likely are a candidate for full anticoagulation with either warfarin or the new anticoagulant drugs. Consultation with an electrophysiologist is recommended.

Nance: While hospitalized for atrial fibrillation, I was told by the cardiologist at the hosp. that I should stop Omega 3 supplements. He claims that fish oil and krill oil contribute to A-fib. So, far, no other doctor that I have spoken to about fish oil supplements agrees with his statement. What is your opinion on fish oil or krill oil supplements and their effect on atrial fibrillation? Thank you.

Dr_Baez-Escudero: There has been no clear-cut association between fish oil and atrial fibrillation. The latest trials in cardiovascular prevention with the use of these supplements have been negative, meaning there is no clear improvement of the overall cardiovascular risk with these drugs.

Nance: I have had two electrocardioversions for A-fib, 3 months apart. Both were successful. How many of these procedures can a person have should their fibrillation return?

Dr_Baez-Escudero: There is not a specific number or limit in the number of cardioversions. However if atrial fibrillation recurred after the first one and you required a second procedure, is likely that you will need either antiarrhythmic therapy or catheter ablation in order to prevent a third recurrence.

Lulubond:This question deals with velocity of blood flow through the atrial appendage after successful catheter ablation. During the ablation procedure, it was necessary to isolate the left atrial appendage. The result of that procedure left a reduced flow/velocity through the appendage of 0.25meters per second; a second flow velocity was .19. The left atrial appendage opening is enlarged, measuring 1.7 cm in one dimension. With the heart is sinus rhythm, does the reduced velocity of blood flow create an appreciatable risk of blood clots, and thus stroke? Is there any research of such a situation where sinus rhythm is obtained but the flow velocity through the left atrial appendage is reduced? Does such a reduction in velocity create the same risk of clotting that a heart in atrial fibrillation creates? This question is for information only and does not seek any medical opinion from the Cleveland Clinic.

Dr_Baez-Escudero: To my knowledge there is no specific literature or trials looking at the risk of stroke in patients that have had electrical isolation of the left atrial appendage. However, one can assume that if the appendage lacks contractility because of electrical isolation and therefore has low emptying velocities, it is theoretically possible to have a similar stroke risk as if the appendage would be fibrillating. For those patients who do require isolation of the left atrial appendage during ablation, our personal practice has been to continue anticoagulation indefinitely versus targeting the left atrial appendage percutaneously with either an occluder device, or exclude it epicardially.

bas46: I have been told there is a blood test that can be done to test for LQTS. Is this true? May you talk in detail about this?

Dr_Baez-Escudero: There are several types of long QT syndromes. Some mutations associated with the syndromes can be identified with genetic testing. A genetic test for long QT syndrome is available and increasingly covered by private and governmental insurance plans. Current genetic tests for long QT syndrome are capable of finding the genetic cause for about 3 out of every 4 cases of long QT syndrome. Therefore, it's possible to test negative with the genetic test, but still have long QT syndrome. If your genetic cause of long QT syndrome is discovered through a positive genetic test, then family members can be tested to prove definitively whether they inherited the same genetic mutation.

dsm08: I was wondering if being in bigeminy most of the day can have a long term effect on your heart? Also can anxiety contribute to bigeminy? What treatment options are available for this arrhythmia? I have had some lightheadedness with this while doing some activities.

Dr_Baez-Escudero: It depends whether the bigeminy comes from the atrium or from a premature ventricular contraction (PVC). Ventricular bigeminy has been sometimes associated with PVC-induced cardiomyopathy. This basically means that the heart can get weak over time if you are in constant bigeminy. Anxiety can be a contributing factor. Catheter ablation of a PVC causing bigeminy can be curative. Consultation with an electrophysiologist is warranted.

DanR: Specific to afib ablation surgery, does the patient need to be in afib during the procedure? If not, how do they know where to burn or freeze?

Dr_Baez-Escudero: We routinely perform atrial fibrillation ablation in both patients that present in sinus rhythm as well as in atrial fibrillation. Patient is not present and normal sinus rhythm are more likely to have paroxysmal atrial fibrillation. For these patients we empirically target the anatomic structure called pulmonary veins. This is where most of atrial fibrillation triggers occur anatomically. For patients that present in atrial fibrillation at the time of the ablation, often more extensive ablation is needed within the left atrium. Atrial fibrillation often terminates during the ablation procedure and normal sinus rhythm is restored while we are burning. Sometimes we have to perform cardioversions during the atrial fibrillation ablation procedure because after we have completed our ablation lesions we often tested for inducibility of the arrhythmia. It is not uncommon to have one or 2 cardioversions during a pulmonary vein ablation.

Ed95: Rate vs Rhythm. I'm aware that research shows no significant difference in life expectancy between rate control vs rhythm control. If the heart rate is properly controlled and creating no ill effects on the patient, are there any other reasons (short or long term) to avoid and just remaining in afib.

Dr_Baez-Escudero: This is supported by data from AFFIRM. A reason to avoid atrial fib would be the risk of stroke. Most strokes in AFFIRM occurred either during subtherapeutic INR, or after cessation of warfarin. Since more patients in the rhythm control arm of AFFIRM discontinued warfarin, it is possible that asymptomatic recurrences of paroxysmal AF fostered clot development and embolization. We cannot answer from the data available whether or not it is safe to discontinue anticoagulation if all episodes of AF are suppressed. Among the reasons that AF is associated with increased mortality may be that it encourages development of congestive heart failure or progressive left ventricular dysfunction. Congestive heart failure occurrence was monitored in both trials, and occurred at a rate of 2-5% without significant differences between rate and rhythm arms. In patients with heart failure at entry, a mortality trend in AFFIRM favored the rhythm control arm. The issue of survivorship and rhythm control in AF in congestive heart failure is undergoing further testing.

Cr: Is there any relationship between low magnesium/ low electrolytes and atrial fibrillation?

Dr_Baez-Escudero: Electrolyte abnormalities can be triggers for atrial and ventricular arrhythmias.

dave_s: What should patient do at home during mild AFIB attacks occurring every 1 to 2 weeks, which are mild but are still debilitating (79 year old man)?

Dr_Baez-Escudero: There are several options that you have including antiarrhythmic drug therapy to prevent recurrence of episodes and possibly catheter ablation of atrial fibrillation. I recommend you consult with an electrophysiologist.

RGambatese: I recently had an aortic valve replacement along with a septal myectomy. I had a few episodes of AFIB prior to the surgery in November. I'm currently on Coumadin and wondering if Pradaxa would work as well for me in spite of not being approved for AFIB caused by a valve issue?

Dr_Baez-Escudero: It is unlikely that your aortic valve disease was the cause for atrial fibrillation. He had septal myectomy you more likely had hypertrophic cardiomyopathy. It is possible that this was the cause for atrial fibrillation rather than your aortic valve. Patients with this particular type of profile are usually considered to have non-valvular atrial fibrillation and are good candidates for Pradaxa, assuming they can tolerate the drug and that your kidney function is normal.

SLandric: Are nsvt's dangerous in a structurally normal heart with ejection fraction of 65 % and asymptotic ? When would ablation or ICD be warranted?

Dr_Baez-Escudero: Nonsustained ventricular tachycardia in the setting of a structurally normal heart is usually not life-threatening. Therapy for these types of ventricular tachycardia is mandated by both the symptoms of the patient and the frequency of the episodes. If you're asymptomatic in your ejection fraction is normal, he probably don't require any specific therapy. If the frequency of these ventricular tachycardias is causing your heart to become weak and then it may be warranted to have a catheter ablation procedure. In general ICD's are not indicated in this setting.

Pabestco: I’m 43 years old, male, in 1999 my heart started beating really fast and hard one day for no apparent reason and has been doing so often up to last night, I ran many tests and was diagnosed with mvp and was put on Lopressor as a beta blocker, I went to another doctor some time later and did ECG AND EKG and they came out perfect and I was told I don’t have MVP. I need to know what to do because I also have sleep apnea and it’s a very scary thing to not know what’s happening with me. I can be sitting just talking and my heart would just speed up very fast and the beats are very hard, dizziness and slight pains in the legs back of the neck and hands are present with shortness of breath.

Dr_Baez-Escudero: The only way to diagnose mitral valve prolapse is with an echocardiogram. A lot of times people with palpitations are labeled as having mitral valve prolapse when in reality this is not a common finding on echocardiogram, nor is it associated with any specific rhythm abnormalities. Sleep apnea puts you at risk for atrial fibrillation. The symptoms you are describing could be related to atrial fibrillation. The only way to diagnose this would be to connected to a 30 day event monitor and hopefully catch an episode while wearing it.